Primary Linked Semiconstrained Total Elbow Arthroplasty for Rheumatoid Arthritis: A Single-Institution Experience with 461 Elbows Over Three Decades

Abstract

Background: Elbow arthroplasty is the treatment of choice for end-stage rheumatoid arthritis (RA). The purpose of this study was to determine the long-term outcome of a linked semiconstrained elbow arthroplasty implant design in patients with RA.

Methods: Between 1982 and 2006, 461 primary total elbow arthroplasties using the Coonrad-Morrey prosthesis were performed in 387 patients with RA. Fifty-five of the arthroplasties were performed to treat concurrent traumatic or posttraumatic conditions. There were 305 women (365 elbows, 79%) and 82 men (96 elbows, 21%). Ten patients (10 elbows) were lost to follow-up, 9 patients (10 elbows) died, and 6 patients (6 elbows) underwent revision surgery within the first 2 years. For the 435 elbows (362 patients, 94%) with a minimum of 2 years of follow-up, the median follow-up was 10 years (range, 2 to 30 years).

Results: At the most recent follow-up, 49 (11%) of the elbows had undergone component revision or removal (deep infection, 10 elbows; and mechanical failure, 39 elbows). Eight additional elbows were considered to have radiographic evidence of loosening. For surviving implants followed for a minimum of 2 years, the median Mayo Elbow Performance Score (MEPS) was 90 points. Bushing wear was identified in 71 (23%) of the surviving elbows with a minimum of 2 years of radiographic follow-up; however, only 2% of the elbows had been revised for isolated bushing wear. The rate of survivorship free of implant revision or removal for any reason was 92% (95% confidence interval [CI] = 88% to 94%) at 10 years, 83% (95% CI = 77% to 88%) at 15 years, and 68% (95% CI = 56% to 78%) at 20 years. The survivorship at 20 years was 88% (95% CI = 83% to 92%) with revision due to aseptic loosening as the end point and 89% (95% CI = 77% to 95%) with isolated bushing exchange as the end point. Risk factors for implant revision for any cause included male sex, a history of concomitant traumatic pathology, and implantation of an ulnar component with a polymethylmethacrylate surface finish.

Conclusions: Elbow arthroplasty using a cemented linked semiconstrained elbow arthroplasty provides 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 identified on radiographs in approximately one-fourth of the patients, revision for isolated bushing wear was uncommon.

Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Figs. 1-A through 1-D

Kaplan-Meier curves for all primary total elbow arthroplasties (TEAs) for RA included in this study, showing the survivorship estimates (solid line) and the pointwise 95% confidence intervals (dashed 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), and revision for isolated bushing exchange (Fig. 1-D) as the end points.

Figs. 1-A through 1-D

Kaplan-Meier curves for all primary total elbow arthroplasties (TEAs) for RA included in this study, showing the survivorship estimates (solid line) and the pointwise 95% confidence intervals (dashed 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), and revision for isolated bushing exchange (Fig. 1-D) as the end points.

Figs. 1-A through 1-D

Kaplan-Meier curves for all primary total elbow arthroplasties (TEAs) for RA included in this study, showing the survivorship estimates (solid line) and the pointwise 95% confidence intervals (dashed 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), and revision for isolated bushing exchange (Fig. 1-D) as the end points.

Figs. 1-A through 1-D

Kaplan-Meier curves for all primary total elbow arthroplasties (TEAs) for RA included in this study, showing the survivorship estimates (solid line) and the pointwise 95% confidence intervals (dashed 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), and revision for isolated bushing exchange (Fig. 1-D) as the end points.

Figs. 2-A and 2-B

Anteroposterior (Fig. 2-A) and lateral (Fig. 2-B) radiographs 20 years after total elbow arthroplasty performed in a 41-year-old female patient. Note the absence of radiolucent lines or substantial wear. This patient reported no pain and had an excellent MEPS. P.O. = postoperative.

Figs. 2-A and 2-B

Anteroposterior (Fig. 2-A) and lateral (Fig. 2-B) radiographs 20 years after total elbow arthroplasty performed in a 41-year-old female patient. Note the absence of radiolucent lines or substantial wear. This patient reported no pain and had an excellent MEPS. P.O. = postoperative.

Figs. 3-A and 3-B

Anteroposterior (Fig. 3-A) and lateral (Fig. 3-B) radiographs 21 years after a total elbow arthroplasty performed in a 50-year-old male patient with RA. Note the presence of polyethylene wear.

Figs. 3-A and 3-B

Anteroposterior (Fig. 3-A) and lateral (Fig. 3-B) radiographs 21 years after a total elbow arthroplasty performed in a 50-year-old male patient with RA. Note the presence of polyethylene wear.

Fig. 4

Kaplan-Meier curves for primary total elbow arthroplasty (TEA) performed for RA, showing the survivorship estimates for survival free of ulnar component revision or resection for mechanical failure according to the type of surface finish of the ulnar component.