General Introduction. Development of elbow prostheses

Transcription

1 1INTRODUCTION

2 Chapter 1 10

3 Introduction General Introduction Development of elbow prostheses The elbow joint is a semi-constrained joint with three articulations: ulnotrochlear, radiocapitellar and proximal radioulnar (Figure 1). Flexion-extension movements need an intact ulnotrochlear joint, whereas pro- and supination movements need both radiocapitellar and proximal radioulnar joints as well as distal radio-ulnar joints. The initial stability is caused by the shape of bones, whereas the collateral ligament complexes are important in the functional stability during movements (Morrey 2000, Eygendaal 1999). The normal range of motion approximates 0 o of extension to 145 o of flexion and 80 o of pronation to 85 o of supination. The functional range of motion is between 30 o of flexion to 130 o of flexion and 50 o of pronation to 50 o of supination (Morrey 1981). The average position of the flexion/extension axis is 0.82 cm cranially and 1.86 cm ventrally of the lateral epicondyle. The average elbow angle in the frontal plane is 15.3 degrees (Stokdijk 1999). The causes for elbow joint destruction are variable. They include rheumatoid arthritis, hemophilia, synovial chondromatosis, crystalline arthropathy, osteonecrosis, posttraumatic arthritis and primary osteoarthritis, the latter has varying prevalence figures ranging from 2 to 29 % (Nelissen 2009, Sooijan 2007). Fig. 1. Anatomy of the elbow, anterioposterior and lateral view. 11

4 Chapter 1 Pain is the most common complaint in elbow arthritis. Patients typically suffer from pain at night and during weight bearing (i.e. rising from a chair). The secondary complaint is restricted function, mainly flexion but also loss of reach, because of the joint erosions. Both problems guide the treatment options in elbow arthritis. The first step in the treatment of the rheumatic arthritic elbow is the use of analgesic medication, often nonsteroidal anti-inflammatory drugs (NSAIDs). In rheumatoid patients oral steroids, disease-modifying anti-rheumatic drugs (DMARDS) and the socalled biologicals like antitnf-alpha can be considered (Keystone 2009, Murphy 2002). If these treatment options fail, open or arthroscopic synovectomy is indicated when joint destructing is still of minor degree (Larsen grade 2 or less) (Larsen 1977). In case of more severe elbow joint destruction other operative options can be considered (Nelissen 2009, O Driscoll 1993). At the beginning of the 20 th century up to the 70 s of the last century, the surfaces of the destructed elbow joint were resected and the cavity was filled with a muscle or skin flap (resection arthroplasty), or the elbow joint was fixed rigidly in a flexed position (arthrodesis). Although these procedures caused pain reduction, the function of the arm during daily activities was limited. A resection arthroplasty resulted often in an unstable (i.e. floppy ) elbow joint with inability to guide the hand in the surrounding space (Fernandez-Palazzi 2008). Furthermore, shortening of the forearm occurs due to the joint resection, with subsequent weakening of the wrist and hand muscles. Simple tasks like picking up a cup of tea can become difficult after such treatment. Resection arthroplasty is performed nowadays as a salvage procedure after failed total elbow prosthesis (Yamaguchi 1998). Arthrodesis of the elbow joint ensures a stable arm with stable positioning of the hand, but the function of the arm is severely restricted (Rashkoff 1986). Professional and other daily activities of the patient are important in determing the needed degree of postoperative function. Thus, in discussion with the patient the surgeon can decide, for example, to fixate the elbow joint in a more flexed position to fulfill his daily work. Assessment of the function of the ipsilateral shoulder and wrist, for example by using the Quick- DASH score, has to be considered before the arthrodesis can take place (Angst 2009). We noticed great variability in elbow scoring systems, this complicates the comparison between postoperative outcome scores from different studies. Most scores count from 0 to 100 points, but the value for the individual score items can differ. We advocate the use of the validated Elbow Functional Assessment scale (EFA-scale, table 1), because this assessment has the highest power to detect a clinically meaningful difference compared to other elbow scoring systems (De Boer 2001). The first part of the EFA-scale has to be filled in by the patient, whereas the second part should be filled in by the medical doctor. 12

5 Introduction Table 1. Elbow Function Assessment (EFA) I Pain (max = 30 points) 1. Pain sensation at rest (on 10 cm VAS scale, no pain is 10 points) 2. Pain sensation on motion (on 10 cm VAS scale multiplied by two, no pain is 20 points) II Activities of Daily Life (ADL, max = 35 points) * 1. Cup to mouth 2. Eating with a spoon 3. Lifting a kettle with one litre 4. Pouring water from a kettle to a glass 5. Telephone receiver to ipsilateral ear 6. Cutting with a knife 7. Pulling an object over the table III Motion (max = 35 points) Active range of motion (max = 25 points) Active flexion 125 o = o = o = 5 < 75 o = 0 Flexion contracture 20 o = o = 5 40 o = 0 Combined movement (max = 10 points) Grasping ear lobe of contralateral side with arm in front of the body Possible without difficulty = 10 Possible with difficulty = 5 Impossible = 0 * on a selfreported questionnaire for the ipsilateral arm. Without difficulty = 5, with little difficulty = 3, with much difficulty = 2, with aid = 1, impossible = 0. Total elbow arthroplasty is indicated in severely destructed elbow joints, at least Larsen grade 3 and 4 (Larsen 1997). Although rheumatoid arthritis is the main cause for elbow destruction, in recent years the indications for elbow replacement therapy are shifting. Also in elderly patients with intraarticular fractures of the elbow joint, this procedure can be considered to gain an early, good postoperative result. Since 1973 implantation of elbow prostheses, developed by Dee, is increasing, probably due to increased expectations of the elbow function postoperatively (Dee 1973). First, hinged ( constrained ) prostheses were developed with fixation in the humerus and ulna. 13

6 Chapter 1 After a few years, bad short-term outcome results became available, mainly caused by frequent aseptic loosening of the components. Consequently, semi-constrained prostheses were developed in order to have less strain at the prosthesis-bone-interface due to the less rigid coupling between the humeral and ulnar components (Gschwend 1972). Although the elbow prosthesis stability is not only warranted by the component-coupling, the collateral ligament complexes are of importance as well. The latter is even more important in the non-constrained elbow prostheses which were developed in 1972 (Kudo 1980). Beside these three different coupling mechanisms of the elbow components (constrained, semi-constrained and non-constrained), experiments were done with cemented and non-cemented fixation of the components in the bone. Due to inferior results of the non-cemented prostheses at long-term follow-up, particularly for the ulnar components, most prostheses are cemented these days (Van der Heide 2007). In recent years some series were published about elbow prostheses for osteoarthritic joints. Primary osteoarthritis of the elbow is rare and mostly related to repeated microtraumata (i.e. heavy workers) (Nelissen 2009). Because this patient population is younger, and thus has higher functional demands than the rheumatoid arthritis patients, the long-term success for total elbow arthroplasty is limited (Cheung et al 2008). The non-constrained Souter-Strathclyde total elbow prosthesis was developed in 1973 and used since 1982 at our center (Souter 1981, Pöll 1991, Rozing 2000, Valstar 2002, Van der Lugt 2004). The humeral component is made of Vitallium and has a flat intramedullary stem for fixation in the epicondylar ridges, with flanges for the lateral and medial epicondyle of the humerus. The ulnar component is made of ultra-high-molecular-weight polyethylene and has a keel and small stem (Figure 2). The short-term results of the Souter-Strathclyde elbow prosthesis (2 to 8 years) showed that it is a satisfactory treatment for the painful and destructed elbow joint, especially in rheumatoid arthritis (Pöll 1994). In recent studies about elbow arthroplasties showed similar results at longterm follow-up (Trail 2002, Rozing 2000). Septic (1 to 10%) and aseptic loosening (1 to 5%) of the components and ulnar nerve injuries (1 to 2%) occurred more often than in, for example, hip en knee prostheses (Van der Lugt 2004). In our series septic loosening was mainly caused by secondary infected rheumatoid noduli at the dorsum of the elbow joint (Van der Lugt 2004). The larger amount of aseptic loosening in elbow arthroplasty compared to most other joint replacements could be related to rheumatoid arthritis. The mineral bone density in rheumatoid affected bone is lower than in normal bone which may have a negative effect on fixation of the prosthetic components in the bone (Shibuya 2002). In addi- 14

7 Introduction Fig. 2. Standard Souther-Strathclyde total elbow prosthesis. Fig. 3. Tumor resection elbow prosthesis tion, the rheumatoid disease also deteriorates other joints, for instance the shoulder and wrist joint. If these adjacent joints are deteriorated and a limited and painful range of motion occurs, the loads on the elbow prosthesis will increase as a consequence. The survival rates of elbow prostheses vary between 74 to 92 % after 10 years of follow-up (Soojian 2007). If revision surgery is necessary, the potential bone loss which is related to the primary surgery (i.e. linked long-stemmed components have more bone loss) is determing the options for revision surgery, sometimes necessitating the implantation of tumor resection prostheses (Figure 3). In literature less is known about the outcome of revision surgery for failed elbow replacements (Van der Lugt 2006). The presented series are small and the surgical techniques differ among elbow surgeons. Bone-impaction grafting, use of metal meshes, custom made components and components with long stems have all been used for this type of surgery (Loebenberg 2005, Sneftrup 2006). Aim of this thesis The first goal of this thesis was to evaluate the results of primary elbow prostheses used in rheumatoid patients. A systematic review on elbow prostheses is given, with special emphasis on the complication rates (Chapter 2). 15

8 Chapter 1 The second goal was to evaluate the long-term results of 204 primary Souter-Strathclyde total elbow prostheses in rheumatoid arthritis patients at the Leiden University Medical Center (Chapter 3). Highlights on the surgical technique are presented (Chapter 4). The third goal was to assess the reasons for failure of the Souter-Strathclyde total elbow prosthesis. Potential failure mechanisms might be related to previous surgery, prosthetic size and position and bone stock. In Chapter 5 to 8 these aspects are presented. Three failure mechanisms are evalated more closely: 1. Previous surgery Some rheumatoid patients with synovitis of the elbow joint first undergo a synovectomy before replacement therapy is chosen. It was hypothesized that previous open synovectomy could harm the outcome of primary elbow prostheses because of scare tissue with increased chance on infection and limited range of motion. 2.Prosthetic position The prosthetic alignment was determined by measuring conventional radiographs during the follow-up in a standardized manner. Since radiolucent lines (RLLs) are the radiological indication in the loosening process, the elbow components position in the bone was related to the development and progression of these RLLs. It was hypothesized that prosthetic position did influence the loosening process. Radiostereometric analysis (RSA) is used for accurate migration measurements during the follow-up of prostheses (Kärrholm 1994, Ryd 1995, Valstar 2002). Aseptic loosening starts with early onset prosthesis migration. Evaluation of migration patterns with RSA during long term follow-up might elucidate this process. 3.Biomechanical prosthesis-bone interface failure The size of the component, related to the bone size, on torsional stiffness and torque to failure was tested in a cadaveric study design. The hypothesis that larger components give more torque strength was investigated. Finally, the last goal was to evaluate the outcome of revision surgery after failure of a primary Souter-Strathclyde total elbow prosthesis (Chapter 9). 16

9 Introduction References Angst F, Goldhahn J, Drerup S, Flury M, Schwyzer HK, Simmen BR. How sharp is the short QuickDASH? A refined content and validity analysis of the short form of the disabilities of the shoulder, arm and hand questionnaire in the strata of symptoms and function and specific joint conditions. Qual Life Res. 2009;18(8): Cheung EV, Adams R, Morrey BF. Primary osteoarthritis of the elbow: current treatment options. J Am Acad Orthop Surg. 2008;16(2): De Boer YA, Hazes JM, Winia PC, Brand R, Rozing PM. Comparative responsiveness of four elbow scoring instruments in patient with rheumatoid arthritis. J Rheumatol. 2001;28(12): Dee R. Total replacement of the elbow joint. Orthop Clin North Am. 1973;4(2): Eygendaal D, Olsen BS, Jensen SL, Ski A, Söjbjerg JO. Kinematics of partial and total ruptures of the medial collateral ligament of the elbow. J Shoulder Elbow Surg. 1999;8(6): Fernandez-Palazzi F, Rodriguez J, Oliver G. Elbow interposition arthroplasty in children and adolescents: long-term follow-up. Int Orthop. 2008;32(2): Gschwend N, Scheier H, Bähler A. [Elbow arthroplasty with the new GSB-prosthesis] Arch Orthop Unfallchir. 1972;73(4): Kärrholm J, Borssén B, Löwenhielm G, Snorrason F. Does early micromotion of femoral stem prostheses matter? 4-7-year stereoradiographic follow-up of 84 cemented hip prostheses. J Bone Joint Surg (Br) 1994;76: Keystone E. Recent concepts in the inhibition of radiographic progression with biologics. Curr Opin Rheumatol. 2009;21(3):231-7 Kudo H, Iwano K, Watanabe S. Total replacement of the rheumatoid elbow with a hingeless prosthesis. J Bone Joint Surg Am. 1980;62(2): Larsen A, Dale K, Eek M. Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol Diagn (Stockh). 1977;18(4): Loebenberg, M.I., Adams, R., O Driscoll, S.W., Morrey, B.F. Impaction grafting in revision total elbow arthroplasty. J. Bone Joint Surg. Am. 2005;87(1), Morrey BF. Anatomy of the elbow. In: Morrey BF (ed). The Elbow and Its Disorders (3rd ed). Philadelphia: W.B. Saunders Co.,2000, pp Morrey BF, Askew LJ, An KN, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981;63(6): Murphy MS. Management of inflammatory arthritis around the elbow. Hand Clin. 2002;18(1): Nelissen RG. Osteoarthritis of the elbow. Book: The elbow, Treatment of basic pathology. Edited by D.Eygendaal (Springer Verlag) 2009;Chapter 10: O Driscoll SW. Elbow Arthritis: Treatment Options. J Am Acad Orthop Surg. 1993;1(2): Pöll RG, Rozing PM. Use of the Souter-Strathclyde total elbow prosthesis in patients who have rheumatoid arthritis. J Bone Joint Surg Am. 1991;73(8): Pöll, R.G., Souter-Strathclyde total elbow arthroplasty. A prospective clinical study and a biomechanical investigation. Thesis 1994, Leiden University Medical Center, The Netherlands. Rashkoff E, Burkhalter WE. Arthrodesis of the salvage elbow. Orthopedics. 1986;9(5): Rozing P. Souter-Strathclyde total elbow arthroplasty. J Bone Joint Surg Br. 2000;82(8): Ryd L, Albrektsson B, Carlsson L. Roentgen stereophotogrammetric analysis (RSA) as a predictor of mechanical loosening. J Bone Joint Surg (Br) 1995;77(3): Soojian MG, Kwon YW. Elbow arthritis. Bull NYU Hosp Jt Dis. 2007;65(1): Review. Stokdijk M, Meskers CG, Veeger HE, de Boer YA, Rozing PM. Determination of the optimal elbow axis for evaluation of placement of prostheses. Clin Biomech. 1999;14(3): Shibuya, K., Hagino, H., Morio, Y., Teshima, R., Cross-sectional and longitudinal study of osteoporosis in patients with rheumatoid arthritis. Clin. Rheumatol. 21(2), Sneftrup SB, Jensen SL, Johannsen HV, Søjbjerg JO. Revision of failed total elbow arthroplasty with use of a linked implant. J Bone Joint Surg Br. 2006;88(1): Souter WA. A new approach to elbow arthroplasty. Engin. Med. 1981;10: Trail IA, Nuttall D, Stanley JK. Survivorship and radiological analysis of the standard Souter-Strathclyde total elbow arthroplasty. J Bone Joint Surg (Br) 1999;81(1):80-4. Valstar ER, Garling EH, Rozing, PM. Micromotion of the Souter-Strathclyde total elbow prosthesis in patients with rheumatoid arthritis. Acta Orthop Scand 2002;73(3): Van der Heide HJ, De Vos MJ, Brinkman J-M, Eygendaal D, Van den Hoogen FH, De Waal Malefijt MC. Survivorship of the KUDO Total elbow prosthesis comparative study of cemented and uncemented ulnar components. 89 cases followed for an average of 6 years. Acta Orthop 2007;78(2):

10 Chapter 1 Van der Lugt JC, Geskus RB, Rozing PM. Primary Souter-Strathclyde total elbow prosthesis in rheumatoid arthritis. J Bone Joint Surg (Am) 2004;86-A(3): van der Lugt JC, Rozing PM. Systematic review of primary total elbow prostheses used for the rheumatoid elbow. Clin Rheumatol. 2004;23(4): van der Lugt JC, Rozing PM. Outcome of revision surgery for failed primary Souter-Strathclyde total elbow prosthesis. J Shoulder Elbow Surg Mar-Apr;15(2): Yamaguchi K, Adams RA, Morrey BF. Infection after total elbow arthroplasty. J Bone Joint Surg Am. 1998;80(4):