TOTAL ELBOW ARTHROPLASTY: a radiographic outcome study

Xue Susan Bai, MD 1

Jonelle M Petscavage, MD, MPH 2

Alice S. Ha, MD 1

1. University of Washington2. Penn State Hershey Medical Center

SSR 2016

DISCLOSURES

XB has nothing to disclose.

AH: grant from GE

JP: consultant and expert reader for Medical Metrics

Bai, SSR 2016 2/24

INTRODUCTION

Total elbow arthroplasty has become a popular alternative to arthrodesis for patients with end stage arthrosis.

INDICATIONS:Rheumatoid arthritisPost-traumatic arthritisFracture non-unionOsteoarthritisComminuted distal humeral fracture in elderly

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INTRODUCTIONSince its introduction in 1870, total elbow arthroplasty has

evolved through several different designs and types.

Constrained type total elbow arthroplasty required extensive

soft tissue resection.

Unconstrained type total elbow arthroplasty has a

high dislocation rate.

Petscavage JM, Ha AS, Chew FS. Radiologic review of total elbow, radial head, and capitellar resurfacing arthroplasty. Radiographics 2012;32:129-49

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

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INTRODUCTION

Currently the semiconstrained type of total elbow arthroplasty is the most widely used design.

Composed of titanium or cobalt chromium ulnar and humeral stems that are linked by pin and bushing. Bushing is a polyethylene ring between the metal components to reduce friction.

Allows for physiologic flexion/extension and slight varus/valgus motion.

Anterior flange with bone fragment further stabilizes torsional rotation.

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STUDY PURPOSE

Despite increased popularity of total elbow arthroplasty, there are no dedicated systematic evaluations of their radiographic outcomes.

OBJECTIVES:

Determine radiographic outcomes of total elbow arthroplasty

Correlate with clinical outcome

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MATERIALS AND METHODS

IRB-approved 10-year retrospective review was performed of total elbow arthroplasties performed at: University of Washington Medical Center

Harborview Medical Center

Patients were found via Zvision Search Software at the University of Washington (Clario Imaging, Seattle, WA).

Data was obtained from review of patients’ electronic medical records and radiographs on PACS.

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MATERIALS AND METHODS

Statistical methods:

Calculation of complication rates

Fisher’s exact test to determine association between radiographic complication and clinical outcome.

Kaplan-Meier survival curves for radiographic andclinical survival.

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RESULTS

DEMOGRAPHICS:

104 total elbow arthroplasties, 102 patients (2 had bilateral)

Mean age 63.1 years (range, 28-97)

75% female

Mean radiographic follow up: 826 days (range, 19-5570)

Average of 4 radiographs done per patient

Average of 197 days between each radiograph

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RESULTSINDICATION FOR TOTAL ELBOW ARTHROPLASTY

Rheumatoid Arthritis,

31%

Primary Osteoarthritis

, 8%Secondary

Osteoarthritis, 20%

Acute Trauma, 15%

Failed Prior Hardware Fixation,

20%

Elbow Dislocation,

6%

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RESULTS: RADIOGRAPHIC OUTCOME

70 (out of 104 elbows, 67%) developed one or more radiographic complications.

The average time to first complication was 432 days (range 8 to 3500).

Radiographic Abnormality Number (Percentage of total TEAs)

Heterotopic Ossification 50 (49%)

Perihardware Lucency 36 (35%)

Periprosthetic Fracture 24 (23%)

Subluxation/Dislocation 7 (7%)

Wear and Breakdown of Bushing 3 (3%)

Hardware Fracture 3 (3%)

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RESULTSHeterotopic ossification = 49% (50 out of 104 TEAs)

82-year-old woman status post TEA for comminuted supracondylar humeral fracture. (A) Normal postoperative lateral radiograph. (B) AP and (C) lateral postoperative radiographs at 83

days after TEA demonstrate near-ankylosis due to heterotopic ossification across the joint consistent with grade 2 heterotopic ossification (arrows).

6/2006 9/2006

A B C

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RESULTSPerihardware lucency = 35% (36 out of 104 TEAs)

5/2009

60-year-old woman status post TEA for comminuted supracondylar fracture. (A) Lateral immediately postoperative radiograph demonstrates normal postoperative appearance. (B)

Lateral radiograph 30 days after joint replacement demonstrates perihardware lucency greater than 2mm in thickness concerning for loosening (arrows). There is incidental concomitant

olecranon bursitis (arrowhead).

6/2009

A B

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RESULTSPeriprosthetic fracture = 23% (24 out of 104 TEAs)

5/2013 8/2013

52-year-old woman status post TEA for rheumatoid arthritis. (A) Normal frontal appearance postoperative. (B) AP radiograph 3 months postoperatively demonstrates

a Mayo 1 type periprosthetic fracture (arrows)

A B

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RESULTSSubluxation/Dislocation= 7% (7 out of 104 TEAs)

A B

68-year-old woman status post TEA for comminuted left distal humerus

fracture with multiple revisions, including most recent humeral

component removal due to infection. Modified lateral radiograph 6 years

after initial surgery demonstrates frank dislocation of the elbow joint.

63-year-old woman status post TEA for osteoarthritis. Modified lateral radiograph 3 months after surgery

demonstrates subluxation of the ulnar stem outside of the ulnar bony cortex

(arrow).

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RESULTSWear and breakdown of polyethylene bushing = 3% (3 out of 104 TEAs)

12/2005 9/2007

61-year-old man status post TEA for secondary osteoarthritis due to history of prior trauma. (A) AP and lateral radiograph demonstrating normal postoperative appearance (normal valgus/varus angle less than 10 degrees). (B) AP radiograph 2 years later demonstrate

valgus/varus angle to be 22 degrees, suggesting bushing wear.

6°A B

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RESULTSHardware failure = 3% (3 out of 104 TEAs)

40-year-old man with multiple prior elbow hardware as a result of supracondylar fracture status post TEA. (A) AP radiograph demonstrates normal immediate postoperative appearance. (B) AP radiograph 3 years later demonstrates perihardware lucency along with fractured and protruding

pin, representing hardware loosening (arrows).

1/2010 1/2013

A B

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RESULTS: CLINICAL OUTCOME

55% (56 out of 104) of the patients developed clinically significant pain or instability.

Average time of 501 days (range, 8 to 350) to symptom development.

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RESULTS: CLINICAL OUTCOME

30% of the patients required at least 1 additional surgery.

Average time of 978 days to first re-operation.

(A) 63 year old female 3 months status post TEA demonstrates subluxation of the ulnar component outside of the ulnar cortex (arrow). (B) This required a re-operation and

replacement of the loose ulnar component and reinforcement by cerclage wires.

A B

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RESULTS

Of the patients with radiographic complications, 66% of them developed elbow pain compared with 19% of patients without radiographic complications. This was statistically significant.(p=0.001)

Of the patients with radiographic complications, 39% had at least one additional surgery compared with 0% of the patients without radiographic complications. This was not statistically significant.(p=0.056)

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RESULTS At 6 weeks after initial surgery, 50% of the TEAs had

radiographic abnormalities.

At 18 weeks, 50% of the TEAs had significant pain and at 51 weeks, 50% of the TEAs had clinical failure.

Overall, radiographic survival was worse than clinical survival.

Radiographic and Clinical Survival

%survival Clinical SurvivalRadiographic Survival

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LIMITATIONS

Non-standardized reporting of patient’s clinical symptoms and dependence on retrospective clinical reported clinical symptoms.

Multiple orthopedic surgeons with different surgical techniques and experiences performed the surgeries which confounded the results.

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CONCLUSIONS

Radiographic complications are common in patients after total elbow arthroplasty. The most common complications are heterotopic ossification and perihardware lucency.

There is a strong positive association between radiographic findings and clinical outcome after total elbow arthroplasty.

Radiographic findings of failure predate clinical failure.

Thus knowledge of common postoperative radiographic findings is important for the radiologist.

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REFERENCES

1. Petscavage JM, Ha AS, Chew FS. Radiologic review of total elbow, radial head, and capitellarresurfacing arthroplasty. Radiographics 2012;32:129-49.

2. Park SE, Kim JY, Cho SW, Rhee SK, Kwon SY. Complications and revision rate compared by type of total elbow arthroplasty. J Shoulder Elbow Surg 2013;22:1-7.

3. Dee R. Elbow Arthroplasty. Proceedings of the Royal Society of Medicine. 1969;62:1031-1035

4. Dee R. Total replacement arthroplasty of the elbow for rheumatoid arthritis. J Bone Joint Surg Br. 1972; 54: 88-95

5. Friedman RJ, Lee DE, Ewald FC. Nonconstrained total elbow arthroplasty: development and results in patients with functional class IV rheumatoid arthritis. J Arthroplasty 1989;4(1):31–37.

6. Gill DR, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis: a ten to fifteen-year follow-up study. J Bone Joint Surg Am 1998;80(9):1327–1335.

7. Bennett JB, Mehlhoff TL. Total elbow arthroplasty: surgical technique. J Hand Surg Am 2009;34(5): 933–939

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