Total Elbow Arthroplasty in Patients Forty Years of Age or Less. By Andrea Celli, MD, and Bernard F. Morrey, MD

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1 1414 COPYRIGHT Ó 2009 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Total Elbow Arthroplasty in Patients Forty Years of Age or Less By Anrea Celli, MD, an Bernar F. Morrey, MD Investigation performe at the Department of Orthopeic Surgery, Mayo Clinic, Rochester, Minnesota Backgroun: It is generally accepte that prosthetic elbow replacement shoul be avoie in young patients because of an anticipate high rate of early failure. The purpose of this paper was to efine the success, prosthetic survival rate, an problems encountere in patients who were treate with a semiconstraine total elbow arthroplasty when they were forty years of age or less. Methos: We retrospectively reviewe the recors of 758 patients who ha unergone primary arthroplasty with the Coonra-Morrey total elbow prosthesis for any reason between 1982 an We ientifie fifty-five total elbow arthroplasties that ha been performe in forty-nine patients (thirty-eight women an eleven men) who were forty years of age or less (mean, thirty-three years) at the time of the operation an that ha been followe for a minimum of five years. Six patients ha a bilateral proceure. The inication for the arthroplasty was inflammatory arthritis in thirty patients an posttraumatic arthritis in nineteen. Patients with hemophilia or a neoplasm were exclue. The meical recor ata were use to calculate the preoperative an postoperative Mayo Elbow Performance Score. Results: The mean uration of follow-up was ninety-one months. During this perio, twelve (22%) of the elbows ha unergone a subsequent surgical proceure: four because of loosening, three because of triceps weakness, three because of wear, an two because of eep infection. On the basis of the Mayo Elbow Performance Score at the last review, thirty-six results (65%) were consiere to be excellent; fifteen (27%), goo; three (5%), fair; an one (2%), poor. Conclusions: Semiconstraine total elbow arthroplasty in young patients was associate with a 22% revision rate at a mean of ninety-one months, an the rate of revision was significantly higher for patients with posttraumatic arthritis. Despite this revision rate, fifty-one elbows (93%) ha a goo or excellent Mayo Elbow Performance Score. Level of Evience: Therapeutic Level IV. See Instructions to Authors for a complete escription of levels of evience. Various stuies on total elbow arthroplasty have been publishe uring the last ecae, an they have showe improve success rates compare with prior rates 1-7. The inications for total elbow arthroplasty for posttraumatic or egenerative conitions are expaning to inclue younger patients, an this age group can be expecte to have a higher complication rate an less satisfactory implant survival than oler iniviuals. However, little information that specifically aresses this issue is available in the literature. The aim of this stuy was to review the results in patients who ha unergone total elbow arthroplasty with the same linke semiconstraine evice at our institution when they were forty years of age or less 8. The goal was to efine the success an prosthetic survival rates as well as the problems encountere in this young age group. Our hypothesis was that total elbow arthroplasty works less well in younger patients. The proceure is typically employe as a salvage proceure for en-stage arthritis in this patient population, an these patients are also particularly at risk for complications relate to overuse 9. Materials an Methos After receiving institutional review boar approval, we retrospectively reviewe the meical recors of all patients treate with the Coonra-Morrey total elbow arthroplasty at the Mayo Clinic between 1982 an Seven hunre an fifty-eight primary total elbow arthroplasties ha been per- Disclosure: The authors i not receive any outsie funing or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immeiate family, receive, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provie such benefits from a commercial entity (Zimmer). No commercial entity pai or irecte, or agree to pay or irect, any benefits to any research fun, founation, ivision, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immeiate families, are affiliate or associate. J Bone Joint Surg Am. 2009;91: oi: /jbjs.g.00329

2 1415 forme, an sixty-one ha been one in fifty-five patients who were forty years of age or less. After the exclusion of total elbow arthroplasties performe after tumor resection or in patients with a hemophilic conition, fifty-five implants in forty-nine patients (six of whom ha a bilateral arthroplasty) constitute our stuy group. The arthroplasty was performe primarily as a salvage proceure in thirteen patients (two with a bilateral arthroplasty) with rheumatoi arthritis, in seventeen patients (four with a bilateral arthroplasty) with juvenile rheumatoi arthritis, an in nineteen patients with a posttraumatic conition. All of the cases of rheumatoi arthritis an juvenile rheumatoi arthritis were stage 3 or 4 accoring to the Mayo Clinic classification system 8. The patients with a posttraumatic conition all exhibite severe osteoarthritis, nonunion, or gross instability that was thought to be not amenable to any other salvage reconstruction or ha been treate, before the joint replacement, with several (range, two to six) operative proceures that ha faile. The Coonra-Morrey prosthesis (Zimmer, Warsaw, Iniana) use in all patients was a titanium linke semiconstraine implant with cement fixation of both components 8. The implant incorporates an anterior flange an a loose hinge with approximately 7 to 8 of varus-valgus laxity an 7 to 8 of rotational freeom 10. During the stuy perio, three surface preparations were employe for the ulna. The humeral an ulnar components were available in several sizes an lengths to better accommoate anatomic variations. The results of the preoperative an postoperative clinical evaluations were rate with use of the Mayo Elbow Performance Score (MEPS) 8. The maximum score with this system is 100 points: 45 points for no pain, 20 points for >100 of motion, 10 points for joint stability, an 25 points for the capacity to perform selecte aily activities. The results are categorize as excellent (90 to 100 points), goo (75 to 89 points), fair (60 to 74 points), or poor (<60 points). For this stuy, excellent an goo results were consiere to be satisfactory an fair an poor results were consiere to be unsatisfactory. Final followup raiographs, or the reports on raiographic evaluations that the patients ha locally, were examine for raiolucency aroun the implants. Sixteen patients with sixteen involve elbows (29%; three with rheumatoi arthritis, seven with juvenile rheumatoi arthritis, an six with posttraumatic arthritis) returne to our institution for the clinical an raiographic evaluations. All of the other patients were assesse on the basis of evaluations performe after the longest follow-up time by their local physician using the MEPS questionnaire an a table to guie measurement of the range of motion. The reports of raiographic evaluations performe locally were sent to us for review. Statistical Assessment The numerical ifferences between the results for the patients with an inflammatory conition an those with a traumatic conition were assesse with a chi-square statistical analysis. Differences with less than a 5% likelihoo of occurring by chance (p < 0.05) were consiere significant. Comparisons among the iagnostic categories were conucte with use of a two-sample t test, assessing unequal variances. Source of Funing No extramural funs were receive for this stuy. Department infrastructure was use for the preparation of this manuscript. Results Overall Clinical Results The mean patient age in this series was thirty-two years (range, twenty-four to forty years) at the time of total elbow arthroplasty, an the mean uration of follow-up was ninetyone months (range, twenty-four to 242 months). Thirteen elbows (24%) ha the last clinical an raiographic assessments within five years after the surgery, twenty-eight elbows (51%) were evaluate between five to ten years postoperatively, an fourteen elbows (25%) ha the last follow-up more than ten years after the arthroplasty. Two major iagnostic groups were represente in this stuy. Thirty-six replacements (65%) were performe for an inflammatory conition an nineteen replacements (35%) were one for posttraumatic arthritis. The mean preoperative MEPS (an stanar eviation) was 37 ± 15.8 points, an the mean latest postoperative MEPS was 91 ± 13.2 points. Accoring to the MEPS, the result at the latest follow-up evaluation was excellent in thirty-six elbows, goo in fifteen, poor in three, an fair in one (Table I). We also stratifie the patients by iagnosis an assesse the MEPS scores before an after the surgery. In all three subgroups, the ifference between the MEPS before the surgery an that after the surgery was significant (p < for all three groups). Inflammatory Arthritis Juvenile Rheumatoi Arthritis Three men an fourteen women ha juvenile rheumatoi arthritis (see Appenix); four patients ha bilateral implants. Themeanageatthetimeofsurgerywasthirty-oneyears (range, twenty-four to forty years), an the mean time between the iagnosis of juvenile rheumatoi arthritis an the elbow replacement was 19.2 years (range, eleven to twenty-five years). Two patients ha ha a previous arthroscopic synovectomy of the elbow. The average uration of follow-up was ninety-one months (range, twenty-four to 242 months). On the basis of the MEPS, fourteen (67%) of the twenty-one elbows ha an excellent result; six, a goo result; an one, a fair result. Rheumatoi Arthritis One man an twelve women ha rheumatoi arthritis (see Appenix); two patients ha bilateral implants. The mean age of this group at the time of the surgery was thirty-five years (range, twenty-seven to forty years), an the mean time between the iagnosis of rheumatoi arthritis an the elbow replacement was 12.7 years (range, seven to twenty years).

3 1416 TABLE I Preoperative an Postoperative Clinical Finings an Mayo Elbow Performance Score (MEPS) Juvenile Rheumatoi Arthritis (N = 21 Implants) Rheumatoi Arthritis (N = 15 Implants) Posttraumatic Arthritis (N = 19 Implants) Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Pain* None 2 (10%) 16 (76%) 0 12 (80%) 3 (16%) 13 (68%) Mil 5 (24%) 5 (24%) 3 (20%) 3 (20%) 7 (37%) 6 (32%) Moerate 8 (38%) 0 2 (13%) 0 2 (11%) 0 Severe 6 (29%) 0 10 (67%) 0 7 (37%) 0 Mean range of motion (eg) Extension Flexion Pronation Supination Stability* Stable 8 (38%) 21 (100%) 5 (33%) 15 (100%) 9 (47%) 18 (95%) Milly or Moerately stable 11 (52%) 0 8 (53%) 0 4 (21%) 1 (5%) Grossly unstable 2 (10%) 0 2 (13%) 0 6 (32%) 0 Mean score for aily activities (points) Mean MEPS (points) Final outcome* Excellent 0 14 (67%) 0 12 (80%) 0 10 (53%) Goo 0 6 (29%) 0 3 (20%) 1 (5%) 6 (32%) Fair 3 (14%) 1 (5%) (16%) 2 (11%) Poor 18 (86%) 0 15 (100%) 0 15 (79%) 1 (5%) *The values are given as the number of elbows with the percentage in parentheses. Three patients ha ha prior surgery: arthroscopic ébriement an synovectomy ha been performe in two an an interpositional arthroplasty, in one. Accoring to the MEPS, twelve of the fifteen elbows ha an excellent result an three ha a goo result at an average of eightyeight months (range, thirty to 185 months) postoperatively. Posttraumatic Arthritis Seven men an twelve women ha posttraumatic arthritis (see Appenix). The mean age at the time of the elbow replacement was thirty-three years (range, twenty-two to forty years). The mean time between the elbow injury an the replacement was 6.6 years (range, one to thirty-three years), an the average number of previous operations was three (range, one to six). The mean uration of follow-up was 102 months (range, twenty-four to 242 months). Accoring to the MEPS, ten of the nineteen elbows ha an excellent result, six ha a goo result, two ha a fair result, an one ha a poor result. Pain Relief an Motion Relief of pain was similar among the three iagnostic categories. Motion was more restricte before an after the replacement in the group with posttraumatic arthritis. Daily Function Before the surgery, the ability to perform activities of aily living (such as combing the hair, feeing oneself, personal hygiene, an putting on pants an shoes) was severely limite by pain an a restricte range of motion in all three groups. The mean MEPS for function (maximum, 25 points) before the surgery was 1.4 points in the juvenile rheumatoi arthritis group, 6 points in the rheumatoi arthritis group, an 7 points in the posttraumatic arthritis group. After elbow replacement, the mean scores were 21, 24, an 17 points, respectively. Thirty-one (56%) of the fifty-five elbows in the three groups combine were consiere by the patient to cause no ifficulties with any of these activities of aily living at the time of the last follow-up. Raiographic Results Of the fifty-five implants, forty-nine (89%) ha no evience of progressive raiolucency aroun either the humeral or the ulnar component at the time of the final assessment. One elbow in the rheumatoi arthritis group ha a 1-mm-thick raiolucent line aroun <50% of the ulnar component at ten years after the surgery; it was clinically asymptomatic at the time of the most recent assessment. Three elbows, all in the posttraumatic ar-

4 1417 thritis group, ha a complete raiolucent line aroun the ulnar component, with minimal symptoms. One elbow in the posttraumatic arthritis group ha a complete raiolucent line aroun the humeral component an was asymptomatic. One elbow in the rheumatoi arthritis group ha complete loosening of the implant seen raiographically but was not painful an was being observe at the time of this report. Complications an Reoperations There were no intraoperative complications. Three patients in the posttraumatic arthritis group an two in the rheumatoi arthritis group reporte postoperative ulnar nerve sensory eficiency without motor eficiency. The sensory resolve in all of these patients. Two patients ha a superficial woun infection, which was treate effectively with antibiotics. There were fourteen elaye complications (25%): two superficial infections, two eep infections, four cases of aseptic loosening of a precoate ulnar component, three cases of triceps insufficiency, an three implants with bushing wear. These elaye complications evelope in seven of the nineteen patients with posttraumatic arthritis an seven (23%) of the thirty patients with an inflammatory conition. With the small numbers of patients, we coul not ientify a significant ifference between the two groups. Twelve elbows, seven in the posttraumatic arthritis group an five in the two inflammatory arthritis groups, require a revision proceure because of a complication (see Appenix). Four operations were one because of loosening; three, because of triceps weakness; three, because of wear; an two, because of eep infection. The complication rate for the patients with posttraumatic arthritis was significantly greater than that in the groups with inflammatory arthritis (p = 0.02). The mean time after the inex arthroplasty for the twelve reoperations was fifty-nine months (range, nine to 120 months). Comparison of Outcomes Between Inflammatory an Posttraumatic Arthritis Groups There was a significant ifference in the mean MEPS score between the inflammatory arthritis (93 points) an posttraumatic arthritis (84 points) groups (p = 0.03). There was also a significantly greater rate of raiographic evience of loosening in the posttraumatic arthritis group (p < 0.02). Finally, there was a greater rate of reoperations in the posttraumatic arthritis group (37% compare with 11%) (p < 0.05). Discussion Between 1982 to 2003 at our institution, 8% of all total elbow arthroplasties were performe in patients who were forty years of age or less. The forty-nine patients inclue in our stuy were carefully selecte for the arthroplasty, an the arthroplasties represente salvage interventions in two major iagnostic groups: posttraumatic an inflammatory conitions. The salvage character of the operation is reflecte by the fact that all of the patients with a traumatic iagnosis ha ha two or more prior operations, an all of those with inflammatory arthritis ha avance isease 8. The surgical management of these patients is very challenging with few reliable options Synovectomy with ébriement an raial hea resection is recommene for elbows with stage-1 or 2 rheumatoi involvement 11,12. However, elbow replacement is consiere to be the most reasonable option for elbows with stage-2, 3, or 4 rheumatoi involvement, even in a younger patient with consierable loss of bone stock. The stability of the linke implant oes not epen on soft-tissue integrity, an the anterior flange of the implant provies stable fixation of the humeral component even when there is loss of the istal humeral bone. Alternative reconstructive proceures such as arthroesis are problematic in young patients since fusion is ifficult to obtain when the bone stock is eficient 19.More importantly, fusion has a high complication rate an is functionally isabling The use of a istal humeral allograft has been reporte as an option for treatment of posttraumatic conitions in patients who are consiere too young for total elbow arthroplasty 19. However, several major complications have been escribe, incluing nonunion, infection, an graft resorption 23,24. Furthermore, total elbow arthroplasties have been reporte to have less favorable results when they are performe following failure of a reconstruction with a istal humeral allograft 25. Although we i perform allograft reconstruction uring this time perio in selecte circumstances, we believe that the results of this proceure are too unpreictable to be wiely use in the young population 22. Interposition arthroplasty is a viable option for young patients with elbow arthritis However, this technique is not consiere suitable in the presence of extensive bone loss 30 or in patients with gross instability or a fixe eformity 20. Over thetimeofthisstuy,weperforme133interpositionarthroplasties an traumatic arthritis was the inication for ninety-four (71%) of the 133 proceures. During the stuy perio, our postoperative recommenations inclue avoiing lifting of >1 kg repetitively or 4 kg as a single event. On the basis of iscussions with our patients, it appears that the vast majority moifie their aily living activities to follow the postoperative protocol. Most of the overuse complications occurre in the posttraumatic arthritis group. Although the overall complication rate in our series (25%) was high, it is comparable with that reporte in other stuies involving oler populations of patients an is lower than that reporte following some of the alternative proceures We were surprise to learn that a group of oler patients treate at our institution for posttraumatic arthritis with the same prosthetic implant ha similar results 30. Accoring to the MEPS, 83% of the oler patients 30 an 84% of the patients with posttraumatic arthritis in the current stuy ha a satisfactory outcome (a score exceeing 75 points). The outcomes in our patients with rheumatoi arthritis were similar to those reporte for oler patients with rheumatoi arthritis as well 6, In our experience, the most important factors that have negatively influence the results in this younger age group have

5 1418 been involvement of the ominant sie, activity level, an a traumatic iagnosis. This stuy ha several weaknesses. First, it is retrospective an has the inherent weaknesses of such an analysis. Secon, the activity levels of the patients were, at best, estimates. Finally, an most importantly, the majority of the patients i not return to us for a final assessment. Thirty-nine (71%) of the fifty-five evaluations were carrie out by local physicians, which introuces an aitional assessment variable. In conclusion, our experience inicates that elbow replacement in patients who are forty years of age or less can provie goo pain relief an increase the elbow range of motion with an acceptable survival rate of the implant. However, the revision rate is high an we continue to prefer non-replacement options such as synovectomy an interposition arthroplasty when possible. Appenix Tables presenting clinical etails of all subjects in the three subgroups are available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation an click on Supplementary Material ) an on our quarterly CD/DVD (call our subscription epartment, at , to orer the CD or DVD). n Anrea Celli, MD Via 4, Pilastri 3, Carpi (Moena) 41012, Italy Bernar F. Morrey, MD Department of Orthopeic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN References 1. Connor PM, Luneen GA. The rheumatoi elbow: current concepts an controversies. Curr Opin Orthop. 2003;14: Fink B, Krey D, Schmielau G, Tillmann K, Rüther W. Results of elbow enoprostheses in patients with rheumatoi arthritis in correlation with previous operations. J Shouler Elbow Surg. 2002;11: Gill DR, Morrey BF. The Coonra-Morrey total elbow arthroplasty in patients who have rheumatoi arthritis. A ten to fifteen-year follow-up stuy. 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