Lower-extremity joint replacement is quite well-advanced, thanks to a high incidence of disabling osteoarthritis and a 40-plus-year history of development in hip and knee prostheses. Additionally, during the last 5 to 10 years, we have made progress in prosthetic design and reliable surgical techniques for the ankle. In the upper extremity, we have a similar 4-decade development history with anatomic shoulder replacement and now 10-plus years with increasingly reliable reverse total shoulder arthroplasty.
However, techniques for elbow and wrist arthroplasty have been much slower to develop, due to lower incidence of pathology, the unique functional demands on these joints, and prosthetic-design and fixation issues. Still, the Conrad-Morrey family of implants has provided reliable elbow prostheses for more than 20 years. Meanwhile, the indications for elbow arthroplasty have narrowed to inflammatory arthritis and distal humeral fractures and nonunions in patients with lower functional demands. Unfortunately, failure of fixation, infection, and bone resorption do occur after primary elbow arthroplasty; consequently, a small but growing number of patients face revision elbow arthroplasty.
In the November 18, 2020 issue of The Journal, Burnier et al. report the results of revision elbow arthroplasty using a proximal ulnar allograft-prosthetic composite to compensate for missing ulnar bone stock and triceps tendon insufficiency. They clearly explain the surgical technique and report their results among a 10-patient cohort, including details of the 6 cases that required reoperation.
JBJS will continue reporting results of revision joint arthroplasty because members of the orthopaedic community have to manage these very complex cases, and this type of information is helpful to guide treatment decisions and patient expectations. Equally important is the positive impact this information has on further development of surgical techniques and prosthetic designs. Close examination of failure is the fuel for innovative improvement.
Marc Swiontkowski, MD
Several studies have demonstrated good short- and intermediate-term outcomes with total elbow arthroplasty (TEA) to treat acute distal humeral fractures. Now, in the September 20, 2017 issue of The Journal of Bone & Joint Surgery, Barco et al. provide data confirming that TEA provides durable pain relief and motion improvements over a minimum of 10 years, albeit with a number of major complications.
Among 44 TEAs performed in elderly patients with and without inflammatory arthritis whom the authors followed for ≥10 years, the mean Mayo Elbow Performance Score was 90.5 points. Five elbows (11%) developed deep infection that required surgical treatment. The revision-free survival rates for elbows with rheumatoid arthritis were 85% at 5 years and 76% at 10 years, while survival rates for elbows without rheumatoid arthritis were 92% at both time points. That difference was not statistically significant, although men in the study were much more likely to experience a revision than women. Twenty-five of the 44 patients died during the long-term follow-up, but the majority of those had their implant in place.
While reporting on these promising long-term revision-free survival rates, Barco et al. emphasize that complications were “frequent and diverse in nature…and have required a reoperation, including implant revision, in 12 of 44 patients.” So, while the good news is that a majority of patients in this situation will die with a useful joint and sound implant, the authors conclude that “surgeons treating this kind of injury should follow their patients over time and should be prepared to manage a wide array of complications using complex techniques.”