Primary Linked Semiconstrained Total Elbow Arthroplasty for Rheumatoid Arthritis

Transcription

1 1741 CPYRIGHT Ó 2016 BY THE JURNAL F BNE AND JINT SURGERY, INCRPRATED Primary Linke Semiconstraine Total Elbow Arthroplasty for Rheumatoi Arthritis A Single-Institution Experience with 461 Elbows ver Three Decaes Joaquin Sanchez-Sotelo, MD, PhD, Yaser M.K. Baghai, MD, an Bernar F. Morrey, MD Investigation performe at the Department of rthopeic Surgery, Mayo Clinic, Rochester, Minnesota Backgroun: Elbow arthroplasty is the treatment of choice for en-stage rheumatoi arthritis (RA). The purpose of this stuy was to etermine the long-term outcome of a linke semiconstraine elbow arthroplasty implant esign in patients with RA. Methos: Between 1982 an 2006, 461 primary total elbow arthroplasties using the Coonra-Morrey prosthesis were performe in 387 patients with RA. Fifty-five of the arthroplasties were performe to treat concurrent traumatic or posttraumatic conitions. There were 305 women (365 elbows, 79%) an 82 men (96 elbows, 21%). Ten patients (10 elbows) were lost to follow-up, 9 patients (10 elbows) ie, an 6 patients (6 elbows) unerwent revision surgery within the first 2 years. For the 435 elbows (362 patients, 94%) with a minimum of 2 years of follow-up, the meian follow-up was 10 years (range, 2 to 30 years). Results: At the most recent follow-up, 49 (11%) of the elbows ha unergone component revision or removal (eep infection, 10 elbows; an mechanical failure, 39 elbows). Eight aitional elbows were consiere to have raiographic evience of loosening. For surviving implants followe for a minimum of 2 years, the meian Mayo Elbow Performance Score (MEPS) was 90 points. Bushing wear was ientifie in 71 (23%) of the surviving elbows with a minimum of 2 years of raiographic follow-up; however, only 2% of the elbows ha been revise for isolate bushing wear. The rate of survivorship free of implant revision or removal for any reason was 92% (95% confience interval [CI] = 88% to 94%) at 10 years, 83% (95% CI = 77% to 88%) at 15 years, an 68% (95% CI = 56% to 78%) at 20 years. The survivorship at 20 years was 88% (95% CI = 83% to 92%) with revision ue to aseptic loosening as the en point an 89% (95% CI = 77% to 95%) with isolate bushing exchange as the en point. Risk factors for implant revision for any cause inclue male sex, a history of concomitant traumatic pathology, an implantation of an ulnar component with a polymethylmethacrylate surface finish. Conclusions: Elbow arthroplasty using a cemente linke semiconstraine elbow arthroplasty provies satisfactory clinical results in the treatment of RA with a reasonable rate of survivorship free of mechanical failure at 20 years. Although bushing wear was ientifie on raiographs in approximately one-fourth of the patients, revision for isolate bushing wear was uncommon. Level of Evience: Therapeutic Level IV. See Instructions for Authors for a complete escription of levels of evience. Peer Review: This article was reviewe by the Eitor-in-Chief an one Deputy Eitor, an it unerwent bline review by two or more outsie experts. The Deputy Eitor reviewe each revision of the article, an it unerwent a final review by the Eitor-in-Chief prior to publication. Final corrections an clarifications occurreuring one or more exchanges between the author (s) an copyeitors. Disclosure: This stuy was mae possible by CTSA Grant Number UL1 TR from the National Center for Avancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH). These funs were use to pay for statistical services. In aition, one of the authors (B.F.M.) reports royalties receive from Zimmer, the manufacturer of the prosthesis use in this stuy. n the Disclosure of Potential Conflicts of Interest forms, which are provie with the online version of the article, one or more of the authors checke yes to inicate that the author ha a relevant financial relationship in the biomeical arena outsie the submitte work; yes to inicate that the author ha a patent an/or copyright, planne, pening, or issue, broaly relevant to this work; an yes to inicate that the author ha other relationships or activities that coul be perceive to influence, or have the potential to influence, what was written in this work. Disclaimer: The contents of this article are solely the responsibility of the authors ano not necessarily represent the official view of the NIH. J Bone Joint Surg Am. 2016;98:

2 1742 T HE J URNAL F B NE &JINT SURGERY JBJS. RG VLUME 98-A 20 CTBER 19, 2016 Rheumatoi arthritis (RA) is a chronic inflammatory isease of unknown etiology marke by a symmetric, peripheral polyarthritis. It is the most common form of chronic inflammatory arthritis (0.5% to 1% of the ault population worlwie) 1 an often results in joint amage an physical isability, in aition to a variety of extra-articular manifestations. Involvement of the elbow joint is reporte in 20% to 65% of patients with RA 1. Elbow arthroplasty is now accepte as the treatment of choice for patients with en-stage rheumatoi elbow involvement 2,3. Various authors have reporte on the short, mi, an long-term outcomes of elbow arthroplasty for RA using various implant esigns At our institution, for a number of years, the majority of elbow arthroplasties for RA were performe using the same type of linke semiconstraine elbow implant. Some features of the implant, such as the surface finish an the materials use for the bearing surfaces, change over time, but other esign features remaine similar. In a previous stuy, Gill an Morrey reporte a 92% 10-year survival rate in a cohort of 78 elbow arthroplasties performe for RA using the Coonra-Morrey implant (Zimmer), 46 of which ha at least 10 years of followup 11. Few aitional stuies have reporte on the long-term outcome of this elbow arthroplasty implant. In this stuy, we aime to report on the long-term outcome of total elbow arthroplasty performe with use of the Coonra-Morrey implant at a single institution in patients with RA. Materials an Methos Patients Between 1982 an 2006, 461 primary total elbow arthroplasties with use of the Coonra-Morrey prosthesis were performe at our institution in 387 patients with RA. The iagnosis of RA was confirme through a comprehensive review of the meical recor. f the 461 arthroplasties, 55 were performe to treat concurrent acute traumatic or posttraumatic conitions, incluing superimpose posttraumatic arthritis (10 elbows), istal humeral fracture or nonunion (40 elbows), olecranon nonunion (4 elbows), or a combineistal humeral/olecranon nonunion (1 elbow). Table I summarizes the number of arthroplasties performe per year that were inclue in the stuy. There were 305 women (365 elbows, 79%) an 82 men (96 elbows, 21%) with a mean age (an stanareviation) at the time of the inex arthroplasty of 64 ± 11 years an a mean boy mass inex (BMI) of 25 ± 6kg/m 2 (n = 456). nly 67 (15%) of the arthroplasties were performe in patients with a BMI of 30 kg/m 2. Seventy-four patients ha both elbows replace;ofthese,15patients(30elbows) ha simultaneous bilateral elbow arthroplasty. Implants an Proceures All patients receive a Coonra-Morrey linke semiconstraine elbow arthroplasty prosthesis (Zimmer). The technique for implantation of this prosthesis has been escribe previously 11. Antibiotic-loae polymethylmethacrylate (PMMA) was use in all but 4 uncemente replacements. The length of the humeral component was 4 inches (10.2 cm) in 304 elbows, 6 inches (15.2 cm) in 153elbows,an8inches(20.3cm)in4elbows.Therewerenocustom humeral components; 9 proceures were performe using a custom ulnar component. The surface finish of the ulnar component of this implant system was moifie over time 12. Thirty-six ulnar components ha an early (firstgeneration) plasma spray coating, 157 ha a beae porous coating, 140 were TABLE I The Inclue Elbow Arthroplasties Per Year Year No. of Arthroplasties precoatewithpmma,an128haamoernplasmaspraycoating.the mechanism use for component linking was moifie in 1999; the firstgeneration mechanism inclue a titanium pin an a locking ring, whereas the more moern mechanism inclue 2 cobalt-chromium interlocking pins. Evaluation The patients were followe prospectively using a joint registry atabase for ata management. This atabase inclues preoperative clinical information as well as follow-up clinical information recore at regular intervals after the inex proceure (2 years, 5 years, 10 years, an every 5 years thereafter). At each follow-up interval, patients are querie regaring pain, motion, stability, activities of aily living, complications, an reoperations. The information may be collecteuring a follow-up appointment or through the use of a maile or telephone questionnaire. Raiographs are also obtaine at the same time points. For the purpose of this stuy, a researcher inepenent of the treating surgeons retrospectively collecte information from the atabase an reviewe all patient charts to recor pain, motion, scores as assesse with the Mayo Elbow Performance Score (MEPS), complications, an reoperations. Raiographs obtaine prior to the inex proceure, at 3 months postoperatively, an at the most recent follow-up were reviewe to etermine implant fixation an polyethylene wear. f note, wear was not routinely assesse with fluoroscopically positione raiographs or stress fluoroscopy. The uration of clinical follow-up was calculate from the time of the inex arthroplasty until either the most recent patient contact or reoperation

3 1743 T HE J URNAL F B NE &JINT SURGERY JBJS. RG VLUME 98-A 20 CTBER 19, 2016 TABLE II Surgical Revision Proceures with Prosthesis Exchange or Removal in Patients Who Unerwent Primary Total Elbow Arthroplasty for RA Description No. of Elbows Mechanical failure Bushing exchange 9 Ulnar component Aseptic loosening 8 Aseptic loosening an 3 component fracture Aseptic loosening an 8* periprosthetic fracture Aseptic loosening, 4* component fracture, an periprosthetic fracture Component fracture 1 Humeral component Aseptic loosening 3 Aseptic loosening an 2 periprosthetic fracture Humeral an ulnar components Humeral an ulnar aseptic 1 loosening an humeral component fracture Deep infection Humeral an ulnar components 9 Humeral component 1 *Two total elbow arthroplasty revisions require bone-graft struts for construct augmentation. ne total elbow arthroplasty revision require a bone-graft strut for construct augmentation. involving exchange or removal of any component (implant revision or removal). f the 461 consecutive arthroplasties performe in the stuy perio, 10 (2%) of the elbows (10 patients) were lost to follow-up, 10 were in patients who ie within the first 2 years after surgery (9 patients, 2 patients in the first year an 7 in the secon year), an 6 elbows (6 patients) unerwent revision surgery within the first 2 years. The remaining 435 elbows were followe for a minimum of 2 years. The meian clinical follow-up time for all 461 elbows was 9 years (range, 0 to 30 years). For the 435 elbows (362 patients) with a minimum follow-up of 2 years (94% of the initial cohort of elbows), the meian follow-up was 10 years (range, 2 to 30 years). Statistical Analysis Continuous variables are shown as the mean an stanareviation, the mean with the range, the meian with the range, or the meian with the interquartile range (IQR). Categorical variables are expresse as the number with the proportion. A Kaplan-Meier analysis was utilize to etermine the implant survivorship rates an pointwise 95% confience intervals (CIs) for the whole prosthesis an the separate ulnar, humeral, an bushing components, with the en points efine as revision or resection for any reason, revision or resection for mechanical failure, revision or resection for aseptic component loosening, revision for isolate bushing exchange, an revision or resection for eep infection 13. The category of revision for mechanical failure inclues component aseptic loosening, periprosthetic bone fracture in the presence of aseptic loosening, component fracture, an/or bushing wear. A multivariate Cox hazar moel was create to etermine the risks of revision for any reason an inclue sex, age, BMI (nonobese patients with abmiof<30kg/m 2 an obese patients with a BMI of 30 kg/m 2 ), prior elbow trauma, prior elbow surgery, an year of replacement surgery as variables. A univariate Cox moel was also create evaluating the effect of the ulnar surface finish type on the risks of ulnar component revision for mechanical failure. All statistical tests were 2-sie, an the level of significance was set at p < Results Revision Surgery an Component Removal At the most recent follow-up, 49 (11%) of the elbows ha unergone component revision or implant removal (Table II). Deep infection was treate with implant removal or revision in 10 elbows at a meian follow-up of 4 years (range, 0.1 to 20 years). The remaining 39 elbows were revise because of mechanical failureatameianfollow-upof7years(range,0.9to21years). Ulnar component failure was the main reason for revision in 24 elbows. Humeral component failure was the main reason for revision in 5 elbows. ne elbow unerwent revision for combine humeral an ulnar loosening. The remaining 9 (2%) of the elbows unerwent bushing exchange for wear, with retention of the ulnar TABLE III Estimate Total Elbow Arthroplasty Implant Survivorship Rates (%) by En Point* Any Reason Ulnar Component Loosening Humeral Component Loosening Mechanical Failure Aseptic Loosening Isolate Bushing Exchange Deep Infection No. of events Time point 2 yr 99 (97-99) 99 (98-100) 99 (98-100) 99 (98-100) 99 (98-100) (98-100) 5 yr 95 (93-97) 97 (95-98) 97 (95-99) 97 (95-98) 97 (95-98) 99.7 (98-100) 99 (97-99) 10 yr 92 (88-94) 93 (90-96) 97 (95-99) 93 (90-95) 94 (90-96) 99.4 (98-100) 99 (97-99) 15 yr 83 (77-88) 88 (83-92) 97 (95-99) 84 (78-89) 88 (83-92) 96 (90-98) 99 (97-99) 20 yr 68 (56-78) 77 (65-86) 88 (75-95) 76 (66-84) 88 (83-92) 89 (77-95) 89 (75-95) *The values are given as the Kaplan-Meier survival estimate, with the pointwise 95% CI in parentheses. All surgical revision proceures with prosthesis exchange or removal uring the stuy perio were inclue in the analyses.

4 1744 T HE J URNAL F B NE &JINT SURGERY JBJS. RG VLUME 98-A 20 CTBER 19, 2016 an humeral components. f the 6 elbows reviseuring the first 2 years after implantation, 3 unerwent prosthesis removal because of infection an 3 unerwent revision for aseptic loosening. Survivorship Analysis Implant survivorship free of component revision or removal for any reason was calculate for the prosthesis as a whole (any component, incluing revision for isolate bushing exchange) an for the ulnar an humeral components separately (Table III). The rate of survivorship free of revision or removal for any reason was 92% (95% CI = 88% to 94%) at 10 years, 83% (95% CI = 77% to 88%) at 15 years, an 68% (95% CI = 56% to 78%) at 20 years. Using component revision for aseptic loosening as an en point, the survivorship rate at 20 years was 88% (95% CI = 83% to 92%); it was 99% (95% CI = 97% to 99%) for the humeral component an 89% (95% CI = 84% to 93%) for the ulnar component. Using isolate bushing exchange as an en point, the rate of implant survivorship at 20 years was 89% (95% CI = 77% to 95%). verall, approximately one-thir of the arthroplasties ha been remove or revise for any reason at 20 years (Figs. 1-A through 1-D). ther Reoperations an Complications In this stuy cohort, the 90-ay mortality rate was 0.3% for patients (1 of 387 patients) an 0.2% for proceures (1 of 461 Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D Figs. 1-A through 1-D Kaplan-Meier curves for all primary total elbow arthroplasties (TEAs) for RA inclue in this stuy, showing the survivorship estimates (soli line) an the pointwise 95% confience intervals (ashe lines) using revision or resection for any reason (Fig. 1-A), revision or resection for mechanical failure (Fig. 1-B), revision or resection for aseptic loosening (Fig. 1-C), an revision for isolate bushing exchange (Fig. 1-D)as the en points.

5 1745 T HE J URNAL F B NE &JINT SURGERY JBJS. RG VLUME 98-A 20 CTBER 19, 2016 TABLE IV Complications After Primary Total Elbow Arthroplasty for RA* Description No. (%) of Total Elbow Arthroplasties Pulmonary embolism 1 (0.2%) 90-ay periop. mortality 1 (0.2%) Nerve injury 1 (0.2%) Extensor mechanism ysfunction 6 (1%) Bone fracture Intraop. humeral fracture 13 (3%) Intraop. ulnar fracture 5 (1%) Postop. humeral fracture 7 (2%) Postop. ulnar fracture 21 (5%) *Inclues all complications that occurreuring the stuy perio an by the time of most recent follow-up, whether treate operatively or conservatively. arthroplasties). ther complications are summarize in Table IV. A total of 95 elbows (88 patients) unerwent at least 1 aitional proceure after the inex arthroplasty (meian, 1proceure;range,1to8proceures).Fifty-sevenelbows unerwent only 1 aitional proceure, 20 elbows unerwent 2, 9 elbows unerwent 3, 6 elbows unerwent 4, an 1 elbow each unerwent 6, 7, an 8 aitional proceures, respectively (Table V). As mentione previously, 49 elbows unerwent a reoperation involving component revision or removal. f the remaining 46 elbows that unerwent a reoperation with component retention, 26 unerwent 1 irrigation anebriement proceure for eep infection. Thus, the overall rate of eep infection requiring reoperation was 7.8%. Pain an Functional utcomes Subscores for calculating the MEPS were available for 327 (85%) of the 386 elbow arthroplasties with a minimum followup of 2 years an no implant revision or removal. At the most recent follow-up, the meian MEPS was 90 points (IQR, 80 to 100 points). Pain was grae as mil or absent in 285 (87%) of the elbows. The latest arc of motion measurements showe a mean of 20 for extension (range, 0 to 90 ) an a mean of 135 for flexion (range, 50 to 155 ), with a flexion-extension arc of >100 in 234 (72%) of the elbows. The meian MEPS function subscore was 25 points (IQR, 20 to 25 points), with full performance of activities of aily living (i.e., combing the hair, feeing oneself, personal hygiene, an putting on pants an shoes) note for 204 of the elbows. Fig. 2-A Fig. 2-B Figs. 2-A an 2-B Anteroposterior (Fig. 2-A) an lateral (Fig. 2-B) raiographs 20 years after total elbow arthroplasty performe in a 41-year-ol female patient. Note the absence of raiolucent lines or substantial wear. This patient reporte no pain an ha an excellent MEPS. P.. = postoperative.

6 1746 T HE J URNAL F B NE &JINT SURGERY JBJS. RG VLUME 98-A 20 CTBER 19, 2016 TABLE V Reoperations with No Prosthesis Exchange or Removal in Patients Who Ha Primary Total Elbow Arthroplasty for RA* Description No. of Total Elbow Arthroplasties Irrigation anebriement 30 Skin flap coverage 6 Extensor mechanism repair 5 Ectopic bone an heterotopic 2 ossification removal pen reuction an internal fixation for a fracture Ulna 2 Humerus 2 Harware removal 6 Manipulation uner anesthesia 2 Skin rheumatoi noule removal 7 Bursitis 4 Synovectomy 1 Skin granuloma removal 1 *Multiple reoperations with the same or ifferent inications were performe in some elbows. Some reoperations were performe in elbows that eventually require aitional surgery with implant exchange or removal. Raiographic utcomes There were 309 elbows (265 patients) with aequate raiographs at a minimum of 2 years after the inex arthroplasty; these represent 80% of the 386 elbows (334 patients) with a minimum clinical follow-up of 2 years an no implant revision or removal. The meian raiographic follow-up for these 309 elbows was 6 years (range, 2 to 26 years). Raiographic followup was <2 years for 106 elbows, between 2 an 5 years for 109 elbows, between 5 an 10 years for 125 elbows, between 10 an 15 years for 77 elbows, between 15 an 20 years for 35 elbows, an >20 years for 9 elbows. At the most recent follow-up, 301 of the total elbow arthroplasties ha no raiolucency or minor raiolucency (none, type I or type II) aroun both components, 6 aroun the humeral component only, an 1 aroun the ulnar component only (Figs. 2-A an 2-B) 11. ne total elbow arthroplasty ha major raiolucency (type IV or V) aroun both components, 1 aroun the humeral component only, an 6 aroun the ulnar component only, with an ulnar component fracture in 1 elbow. These 8 elbows were consiere to have raiographic evience of loosening but ha not been revise at the most recent follow-up. The bone graft place behin the flange of the humeral component was consiere raiographically to be incorporate in 274 elbows an partially or completely resorbe in 35 elbows. Bushing wear, efine as an intersection angle of >7 between the humeral an the ulnar component, was ientifie on the most recent anteroposterior raiograph in 71 elbows (23% of the surviving elbows with a minimum of 2 years of raiographic follow-up) (Figs. 3-A an 3-B). The results of a subset of elbows followe for a minimum of 10 years are presente in the Appenix. Risk Factors for Revision or Component Removal Men ha a significantly greater risk of revision compare with women (hazar ratio [HR] = 2.49; 95% CI = 1.32 to 4.55; p = 0.006). In aition, patients with concomitant trauma or posttraumatic sequelae ha a significantly greater risk of revision compare with those who i not have a history of elbow trauma (HR = 2.46; 95% CI = 1.12 to 4.97; p = 0.026). The remaining variables analyzei not achieve significance. The effect of the ulnar-surface finish type on the risk of ulnar component revision for mechanical failure was assesse Fig. 3-A Fig. 3-B Figs. 3-A an 3-B Anteroposterior (Fig. 3-A) an lateral (Fig. 3-B) raiographs 21 years after a total elbow arthroplasty performe in a 50-year-ol male patient with RA. Note the presence of polyethylene wear.

7 1747 T HE J URNAL F B NE &JINT SURGERY JBJS. RG VLUME 98-A 20 CTBER 19, 2016 Fig. 4 Kaplan-Meier curves for primary total elbow arthroplasty (TEA) performe for RA, showing the survivorship estimates for survival free of ulnar component revision or resection for mechanical failure accoring to the type of surface finish of the ulnar component. using a univariate analysis. Four surface finishes were compare: early (first-generation) plasma spray coating, beae porous coating, PMMA precoating, an moern plasma spray coating. Compare with the component with the moern plasma spray, the PMMA precoate component was associate with a significantly greater risk of ulnar component revision for mechanical failure (HR = 4.57; 95% CI = 1.27 to 29.23; p = 0.017), whereas the component with the early plasma spray (HR = 1.05; 95% CI = 0.05 to 11.28; p = 0.97) an the porouscoate beae component were not (HR = 1.06; 95% CI = 0.23 to 7.46; p = 0.94). The PMMA precoate component also showe significantly greater risk of ulnar component revision for mechanical failure compare with the porous-coate beae component (HR = 4.30; 95% CI = 1.73 to 12.28; p = ); however, this increase in risk was not statistically etectable when the PMMA precoate component was compare with the component with the early generation of plasma spray (HR = 4.34; 95% CI = 0.87 to 79.11; p = 0.08) (Fig. 4). Discussion The results of our stuy seem to inicate that total elbow arthroplasty with a very commonly use linke semiconstraine implant esign provie satisfactory long-term outcomes in a large cohort of patients with RA. Deep infection, aseptic loosening of the ulnar component, an polyethylene wear were the main reasons for failure. The overall rate of infection requiring revision or reoperation was nearly 8%. Ulnar component revision was the main reason for revision in 24 of the 39 elbows revise for mechanical failure. Bushing wear was ientifie in almost 1 of every 4 surviving elbows with a minimum of 2 years of raiographic follow-up. Deep infection require implant removal or revision in 10 (2.3%) of the elbows. However, the overall infection rate was much higher (7.8%), with 26 aitional elbows requiring ebriement an component retention for eep infection. The relatively high rate of infection following elbow arthroplasty compare with the replacement of other joints nees to be kept in min when counseling patients with RA. Mechanical failure of the ulna was more common for this particular implant. It was particularly high with the PMMA precoate ulnar component. A previous stuy has note the high failure rate of this surface finish, in which component eboning from cement le to flori osteolysis an sometimes periprosthetic fracture 12. This seems to have been resolve with the current plasma spray surface finish. This fining emphasizes the fact that sometimes a single change in component esign can lea to an unexpecte change in failure rates. verall, however, cement fixation of the Coonra-Morrey implant provie long-lasting fixation, as reflecte by a 20-year rate of survivorship free of revision ue to aseptic loosening of 88%. Polyethylene wear is ifficult to assess accurately after elbow arthroplasty In the absence of stress raiographs in varus an valgus, wear can be unerestimate. In this stuy, we assesse wear by measuring the angle between the ulnar an humeral components on the anteroposterior raiograph. Polyethylene wear was ientifie in approximately one-fourth of the surviving elbows with aequate raiographic follow-up of at least 2 years. nly 9 (2%) of the elbows were revise specifically to exchange the polyethylene bushing, but polyethylene wear was also note at the time of revision surgery in most elbows revise for loosening. This fining supports recent efforts by various esigners of moern implants to evelop components with better wear performance. ur stuy ha a number of limitations. Clinical an raiographic information was not available for all patients with a minimum of 2 years of follow-up; aequate raiographs at the most recent follow-up were not available for approximately 20% of the elbows with no history of implant revision or removal. Thus, our stuy may unerestimate the rate of raiographic asymptomatic loosening or polyethylene wear. In aition, the evolution of implant esign ha a major effect on the overall survivorship. Information on triceps function after arthroplasty or sensory changes in the ulnar nerve istribution were not fully capture in earlier meical recors, preventing us from accurately analyzing these aspects of outcome. Lastly, polyethylene wear was not measure on stanarize stress raiographs. Nonetheless, this stuy also ha a number of strengths, incluing, to our knowlege, the largest experience yet reporte in the literature of a continuous series, without exclusion of any elbow operate on, since this particular implant was introuce; clinical an raiographic surveillance of up to 30 years; accurate capture of reoperations an complications; anetaile raiographic evaluation. It is important to emphasize that the characteristics of patients with RA have change over time 1,2.Currently,patients with RA are less affecte by their isease because of the

8 1748 T HE J URNAL F B NE &JINT SURGERY JBJS. RG VLUME 98-A 20 CTBER 19, 2016 introuction of biologic isease-moifying rugs. It is possible that more recent patients with RA are more active than most of the patients inclue in this stuy 19. Thus, the results of our stuy shoul be interprete with caution, since more active patients with RA might be prone to a higher implant failure rate as seen in patients with posttraumatic arthritis 20. It is also important to realize that over the last 2 ecaes, the inications for elbow arthroplasty have been expane to patients without inflammatory arthritis. Patients with acute istal humeral fractures an nonunions, as well as those with posttraumatic osteoarthritis, represent very ifferent patient populations compare with those with inflammatory arthritis. Lessons learne from our experience with elbow arthroplasty for RA may be use only to some extent to improve the outcome of theproceureacrossotherinications.wehavelearne that some aspects of implant esign that may have been introuce in an effort to improve performance can actually result in higher failure rates, making it important to be careful when selecting implants an introucing new esign moifications. We have also learne that, with the correct stem esign an surface finish, stem loosening becomes less of a problem, an polyethylene wear becomes the weak link.finally,we have learnethat non-implant-relate complications, such as ulnar neuritis, triceps insufficiency, fractures, an infection, compromise the clinical outcome of the proceure in patients with surviving implants, an that once a patient evelops a complication neeing reoperation, it sets the stage for possible aitional reoperations. In conclusion, elbow arthroplasty involving the use of a linke semiconstraine cemente implant provie goo clinical results in patients with RA. In this large cohort of patients followe for up to 30 years, the overall revision rate for implant revision or removal was 11%, leaing to a 15-year survival rate of 83% an a 20-year survival rate of 68%. Importantly, failures graually increase with follow-up, a fining that has substantial implications when consiering the treatment of younger, more active patients. Most fixation failures were attribute to a change in the surface finish of the ulnar component. The ecrease in survival between 15 an 20 years seems to be attribute mostly to polyethylene wear. These results will hopefully be of use to counsel patients with RA about the expecte long-term performance of elbow arthroplasty an to etermine whether newer implant esigns truly translate into improve implant longevity. Appenix An appenix escribing the subset of elbows followe for a minimum of 10 years is available with the online version of this article as a ata supplement at jbjs.org. n Joaquin Sanchez-Sotelo, MD, PhD 1 Yaser M.K. Baghai, MD 1 Bernar F. Morrey, MD 1 1 Department of rthopeic Surgery, Mayo Clinic, Rochester, Minnesota aress for J. Sanchez-Sotelo: sanchezsotelo.joaquin@mayo.eu References 1. Stuer A, Athwal GS. Rheumatoi arthritis of the elbow. Han Clin May;27 (2):139-50, v. Epub 2011 Apr Sanchez-Sotelo J, Ramsey ML, King GJ, Morrey BF. Elbow arthroplasty: lessons learne from the past anirections for the future. Instr Course Lect. 2011;60: Epub 2011 May Sanchez-Sotelo J. Total elbow arthroplasty. pen rthop J. 2011;5: Epub 2011 Mar Mukka S, Berg G, Hassany HR, Koye AK, Sjöén G, Saye-Noor AS. Semiconstraine total elbow arthroplasty for rheumatoi arthritis patients: clinical an raiological results of 1-8 years follow-up. Arch rthop Trauma Surg May;135 (5): Epub 2015 Mar Cross MB, Cicalese E, Nam D, McArthur BA, Lipman JD, Figgie MP. Results of custom-fit, noncemente, semiconstraine total elbow arthroplasty for inflammatory arthritis at an average of eighteen years of follow-up. J Shouler Elbow Surg Sep;23(9): Epub 2014 May Qureshi F, Draviaraj KP, Stanley D. The Kuo 5 total elbow replacement in the treatment of the rheumatoi elbow: results at a minimum of ten years. J Bone Joint Surg Br ct;92(10): Epub 2010 ct Prasa N, Dent C. utcome of total elbow replacement for rheumatoi arthritis: single surgeon s series with Souter-Strathclye an Coonra- Morrey prosthesis. J Shouler Elbow Surg Apr;19(3): Epub 2010 Jan Kleinlugtenbelt IV, Bakx PA, Huij J. Instrumente bone preserving elbow prosthesis in rheumatoi arthritis: 2-8 year follow-up. J Shouler Elbow Surg Sep;19(6): Epub 2010 Aug Ikävalko M, Tiihonen R, Skyttä ET, Belt EA. Long-term survival of the Souter-Strathclye total elbow replacement in patients with rheumatoi arthritis. J Bone Joint Surg Br May;92(5): Epub 2010 May Wolfe F, Zwillich SH. The long-term outcomes of rheumatoi arthritis: a 23-year prospective, longituinal stuy of total joint replacement an its preictors in 1,600 patients with rheumatoi arthritis. Arthritis Rheum Jun;41(6): Epub 1998 Jun Gill DR, Morrey BF. The Coonra-Morrey total elbow arthroplasty in patients who have rheumatoi arthritis. A ten to fifteen-year follow-up stuy. J Bone Joint Surg Am Sep;80(9): Epub 1998 ct Jeon IH, Morrey BF, Sanchez-Sotelo J. Ulnar component surface finish influence the outcome of primary Coonra-Morrey total elbow arthroplasty. J Shouler Elbow Surg Sep;21(9): Epub 2011 Nov Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. Journal of the American Statistical Association Jun;53(282): Sanchez-Sotelo J, Morrey BF. Total elbow arthroplasty. J Am Aca rthop Surg Feb;19(2): Epub 2011 Feb Day JS, Baxter RM, Ramsey ML, Morrey BF, Connor PM, Kurtz SM, Steinbeck MJ. Characterization of wear ebris in total elbow arthroplasty. J Shouler Elbow Surg Jul;22(7): Epub 2013 Apr Golberg SH, Urban RM, Jacobs JJ, King GJ, Driscoll SW, Cohen MS. Moes of wear after semiconstraine total elbow arthroplasty. J Bone Joint Surg Am Mar;90(3): Epub 2008 Mar Lee BP, Aams RA, Morrey BF. Polyethylene wear after total elbow arthroplasty. J Bone Joint Surg Am May;87(5): Epub 2005 May Baghai YM, Jacobson JA, Duquin TR, Larson DR, Morrey BF, Sanchez-Sotelo J. The outcome of total elbow arthroplasty in juvenile iiopathic arthritis (juvenile rheumatoi arthritis) patients. J Shouler Elbow Surg Jun 4 Sep;23(9): Epub 2014 Jun Barlow JD, Morrey BF, Driscoll SW, Steinmann SP, Sanchez-Sotelo J. Activities after total elbow arthroplasty. J Shouler Elbow Surg Jun;22(6): Epub 2013 Mar Throckmorton T, Zarkaas P, Sanchez-Sotelo J, Morrey B. Failure patterns after linke semiconstraine total elbow arthroplasty for posttraumatic arthritis. J Bone Joint Surg Am Jun;92(6): Epub 2010 Jun 3.