A critical analysis of alignment factors affecting functional outcome in total elbow arthroplasty

doi:10.1016/S0883-5403(86)80027-4

The Journal of Arthroplasty

Volume 1, Issue 3, 1986, Pages 169-173

https://doi.org/10.1016/S0883-5403(86)80027-4 Get rights and content

Abstract

Fifty-six elbows were evaluated for correlation between implant alignment and functional results following total elbow arthroplasty. Accurate reconstruction of the anatomic center of rotation of the humerus and ulna and accurate placement of the implant stem were correlated with improved durability and decreased complications.

References (9)

AmisAA et al.
Elbow joint force predictions for some strenuous isometric actions
J Biomech
(1980)
AnKN et al.
Muscles across the elbow joint: a biomechanical analysis
J Biomech
(1981)
FiggieHF et al.
A critical analysis of mechanical factors correlated with bone remodeling following total elbow arthroplasty
J Arthro
(1986)
AnKN et al.
Biomechanics of the elbow

There are more references available in the full text version of this article.

Cited by (34)

The Impact of Cement Mantle Characteristics on Early Loosening in Primary Total Elbow Arthroplasty
2022, Journal of Hand Surgery
To assess the association between cement mantle characteristics and early radiographic loosening in total elbow arthroplasty (TEA). We aimed to determine whether shorter mantle heights (<20 mm) were associated with loosening.
We reviewed primary TEAs from a single healthcare system from 2006 to 2020. TEAs complicated by infection or performed for oncologic conditions were excluded. Initial postoperative radiographs were reviewed to determine cement mantle and component characteristics (mantle quality, mantle height, and component angulation). One-year postoperative radiographs were reviewed to assess for implant loosening, and we compared demographics and radiographic criteria for cases with and without early loosening. We noted whether cases underwent subsequent revision for aseptic osteolysis.
A total of 54 TEA cases were included. Forty percent of ulnar and 24% of humeral mantles were classified as short (between 1 and 19 mm). According to the Morrey classification, 6 (11%) cases had an inadequate cement mantle Twenty-four (45%) cases had radiographic evidence of loosening at 1 year. Of the cases with early loosening, 6 (25%) had initial inadequate mantle quality. There were no inadequate mantles in the group without loosening. There were no statistically significant differences in mantle heights for cases with and without loosening at 1 year after surgery. Eight (33%) cases underwent revision in the group with early loosening compared with 1 (3%) case without early loosening.
Inadequate cement mantle quality was associated with an increased risk of early aseptic loosening after primary TEA. Cement mantles that extended past the tip of the prosthesis were not associated with loosening. Considering the potential need for future revision and morbidity of cement removal, surgeons should focus on mantle quality and carefully plan mantle height because shorter heights may not be associated with early implant failure.
Prognostic II.
Biomechanics of Joint Reconstruction
2018, Morrey's The Elbow and Its Disorders
A new posterior triceps approach for total elbow arthroplasty in patients with osteoarthritis secondary to fracture: preliminary clinical experience
2016, Journal of Shoulder and Elbow Surgery
During the past decade, total elbow arthroplasty (TEA) procedures have increased because of an increase in the number of trauma patients. Even though most current posterior approaches to the elbow provide excellent joint exposure, they involve the risk of extensor mechanism injury and of eventual insufficiency, particularly in patients with osteoarthritis (OA) secondary to fracture. I describe a new triceps exposure approach for TEA, the anconeus–triceps lateral flap, which has proved valuable in patients with distal humeral and olecranon fracture malunion, and its preliminary results at a minimum follow-up of 24 months.
Twenty consecutive patients with OA due to distal humeral and olecranon fracture malunion underwent TEA by the anconeus–triceps lateral flap approach, which preserves the olecranon insertion of the medial portion of the triceps proper tendon.
At a mean follow-up of 33 months, the mean Mayo Elbow Performance Score rose from 41.3 to 94.3. The mean pain score on the visual analog scale fell from 7.1 to 1.1. There were no patients with insufficiency, secondary detachment of the triceps tendon, or grade 4 to 5 of the Medical Research Council scale.
These preliminary data suggest that preservation of the insertion of the medial portion of the triceps proper tendon enables earlier active rehabilitation. Moreover, the new approach provides optimum exposure of the olecranon also in patients with OA secondary to intra-articular fracture of the distal humerus and olecranon, where scarring and bone deformity usually hamper joint exposure.
Total elbow arthroplasty: Influence of implant positioning on functional outcomes
2015, Revue de Chirurgie Orthopedique et Traumatologique
La restitution de l’axe de rotation a souvent été évoquée comme un prérequis indispensable du bon résultat fonctionnel des prothèses totales de coude. L’objectif de ce travail était d’étudier si les variations de positionnement étaient corrélées aux résultats cliniques.
Les résultats cliniques dépendent de la qualité du positionnement des implants.
Vingt-cinq patients (26 coudes) ont été revus rétrospectivement avec une évaluation fonctionnelle comprenant une cotation de la douleur, du DASH (Disabilities of the Arm, Shoulder and Hand) et du MEPS (Mayo Elbow Performance Score). Un bilan clinique associant une mesure des mobilités et de la force de flexion et d’extension a également été réalisé. Le positionnement des implants huméral et ulnaire a été évalué par un scanner après reconstruction par le logiciel OsiriX. Des indices d’offset antérieur, d’offset latéral, de valgus, de hauteur et de rotation ont été calculés en soustrayant à la valeur humérale des variables la valeur correspondante sur le versant ulnaire. Ces indices permettaient de quantifier l’addition ou la compensation de malpositionnements associés sur les deux versants de la prothèse. Les prothèses descellées et les coudes présentant des destructions épiphysaires majeures ont été exclus.
Cinq coudes ont été exclus. Sur les vingt et un cas analysés, la discordance entre les offsets latéraux huméral et ulnaire était associée à une altération des douleurs (p ≤ 0,05) et du MEPS (p ≤ 0,05). L’antéposition de l’ulna par rapport à l’humérus était associée à une diminution de la force d’extension (p ≤ 0,05) et de l’ensemble des paramètres fonctionnels (p ≤ 0,05).
En l’absence de descellement, les anomalies de positionnement semblent retentir sur les résultats fonctionnels, probablement en raison de contraintes inappropriées appliquées aux parties molles.
3.
Total elbow arthroplasty: Influence of implant positioning on functional outcomes
2015, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
Very few clinical data are available on the effects of elbow implant position [31,32,47]. In a study of pre-operative and immediate post-operative radiographs, Figgie et al. demonstrated that functional outcomes, implant survival, and complication rates correlated with restoration of anterior offset of the humeral and ulnar components [31]. Nevertheless, their study exhibits several sources of bias.
Restoring the axis of rotation is often considered crucial to achieving good functional outcomes of total elbow arthroplasty. The objective of this work was to evaluate whether variations in implant positioning correlated with clinical outcomes.
Clinical outcomes are dictated by the quality of implant positioning.
A retrospective review was conducted of data from 25 patients (26 elbows). Function was assessed using a pain score, the Disabilities of the Arm, Shoulder, and Hand (DASH) Score, and the Mayo Elbow Performance Score (MEPS). The patients also underwent a clinical evaluation for measurements of motion range and flexion/extension strength. Position of the humeral and ulnar implants was assessed by computed tomography with reconstruction using OsiriX software. Indices reflecting anterior offset, lateral offset, valgus, height, and rotation were computed by subtracting the ulnar value of each of these variables from the corresponding humeral value. These indices provided a quantitative assessment of whether position errors for the two components had additive effects or, on the contrary, counterbalanced each other. Elbows with prosthetic loosening or extensive epiphyseal destruction were excluded.
Of the 26 elbows, 5 were excluded. In the remaining 21 elbows, the discrepancy between the humeral and ulnar lateral offsets was significantly associated with pain intensity (P ≤ 0.05) and the MEPS (P ≤ 0.05). Anterior position of the ulna relative to the humerus was associated with decreased extension strength (P ≤ 0.05) and worse results for all functional parameters (P ≤ 0.05).
In the absence of loosening, positioning errors seem to adversely affect functional outcomes, probably by placing inappropriate stress on the soft tissues.
III.
Elbow hemiarthroplasty using a "triceps-on" approach for the management of acute distal humeral fractures
2015, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
The following parameters were assessed: sagittal and coronal plane component alignment; asymmetric widening of the elbow joint line; presence of radiolucent lines around the implant; ulnar and radial head wear; evidence of condylar union; and presence of heterotopic ossification (HO). Alignment was assessed as described by Figgie et al10 and based on the “parallelism” of the implant to the humeral axis; ≤8° was deemed acceptable and >8° in either plane malaligned. This figure is based on the likelihood of early loosening as a result of malalignment.10
Total elbow arthroplasty is an established option for the primary treatment of acute distal humeral fractures, but there are sparse data regarding elbow hemiarthroplasty (EHA) as an alternative. We present the outcome of EHA performed with a modular anatomic prosthesis and a “triceps-on” surgical technique.
Eighteen consecutive patients underwent EHA for an acute fracture. Two patients died, leaving a study group of 16 patients with minimum 2-year follow-up. Clinical evaluation included range of motion; Mayo Elbow Performance Score; Quick Disabilities of the Arm, Shoulder, and Hand score; and Oxford Elbow Score. Radiographic assessment looked at alignment, evidence of loosening, ulnar and radial head wear, heterotopic ossification, and whether healing of the condyles had occurred.
Mean follow-up was 35 months (24-79 months). The mean scores were as follows: Mayo Elbow Performance Score, 89.6; shortened Disabilities of the Arm, Shoulder, and Hand score, 11.2; and Oxford Elbow Score, 43.7. The mean flexion and pronation-supination arcs were 116° and 172° respectively. Radial head wear was absent in 13 patients and mild in 3. Ulnar wear was absent in 6 patients, mild in 8, and moderate in 2. Wear was not associated with greater pain or inferior functional scores. There was no sign of aseptic loosening, and complete condylar bone union occurred in 15 elbows. There was 1 complication, a transient ulnar nerve neurapraxia that resolved without intervention.
EHA with a modular anatomic implant using a triceps-on approach is a reliable technique for the management of acute unreconstructible distal humeral fractures in older patients.

View all citing articles on Scopus

^*: From the Department of Orthopaedics, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio.

^†: From The Hospital for Special Surgery, New York, New York.

View full text

A critical analysis of alignment factors affecting functional outcome in total elbow arthroplasty

Abstract

J Biomech

J Biomech

J Arthro

Biomechanics of the elbow