Short-term Effectiveness of a Modified Osteotomy for Total Elbow Joint Replacement in Patients of Hemophilic Elbow Arthritis with Severe Flexion Contracture Deformity: A Three-Cases Series Report

Abstract

Objective: To report the modified osteotomy and the short-term effectiveness of the total elbow joint replacement in patients of hemophilic elbow arthritis with severe flexion contracture deformity.

Methods: This study introduced the therapeutic approach of the total elbow joint replacement in patients of hemophilic elbow arthritis with severe flexion contracture deformity, and assessed the short-term effectiveness in three cases (three elbows) of end-stage hemophilic elbow arthritis admitted from October 2020 to December 2020. The included patients were all diagnosed with hemophilia A (factor VII deficiency), accompanied by severe bilateral elbow joint flexion contracture, which seriously affects daily life and requires surgical intervention. Clinical data and follow-up results were analyzed before total elbow arthroplasty and 1, 3, and 6 months postoperatively. Pre- and postoperative range of motion, pain score, and function score were compared, and intraoperative and postoperative complications are reported.

Results: All three patients were male, with an average age of 31 years. The main clinical manifestations were bilateral elbow arthritis with flexion contracture. Two of the patients underwent right elbow replacement, and one patient underwent left elbow replacement. All cases were followed up for 6 months postoperatively. No incision infection or ulnar nerve injury occurred. Postoperative triceps brachii muscle strength was slightly weakened compared with preoperative muscle strength. Average elbow flexion and extension range of motion was 60° (30°-100°) preoperatively and increased to 127° (110°-140°) postoperatively; rotational range of motion of the affected forearm was 47° (10°-85°) preoperatively and increased to 117° postoperatively. The mean visual analogue scale (VAS) was 6 (5-8) preoperatively and decreased to 3 (2-4) postoperatively. The mean MEPS score was 62 (55-75) and increased to 87 (80-95) postoperatively. During the follow-up, anteroposterior and lateral radiographs showed no signs of prosthesis loosening in the elbow.

Conclusions: For severe hemophilic elbow arthritis patients, the short-term treatment effect of total elbow replacement is good, following the strict adherence to the surgical indications and proper preparation for the perioperative period. The modified osteotomy can fully expose the visual field and reduce complications of ulnar nerve injury. The long-term effects need to be study future.

Keywords: Elbow joint function; Hemophilia A; Hemophilic elbow arthritis; Pain score; Total elbow joint replacement.

Fig. 1

The surgical methods. (A) The process of surgical incision and exposure: (i) The insertion of the triceps brachii is dissected along the medial subperiosteum to maintain continuity of tendon and fascia. (ii) The capsule was incised to expose the elbow and proximal ulna. (iii) Excise the olecranon the slender bone of about 2 cm. (B) The process to release contracture tissue in front of elbow joint: (i) Rectangular osteotomy of the humeral pulley was about 2 cm × 4 cm. The depth of osteotomy should be adjusted according to the state of extension after prosthesis installation. (ii) The medial and external malleolus of the humerus was removed and the insertion of the extensor and flexor tendons was preserved. (iii) The prosthesis was sutured with triceps. (C) The process of fitting joint prostheses and closing wounds: after the prosthesis was installed, the insertion of triceps was punch fixed to the proximal ulna with the No. 5 Aixion Bond suture thread. The standard was no avulsion of flexion and extension joints

Fig. 2

The X‐ray of elbow joint of Case 1 before operation, showing that the X‐ray of elbow joint of Case 1 before operation (A: anteroposterior view; B: lateral view)

Fig. 3

Comparison of elbow joint function before and after surgery, showing that before the operation, the patient's elbow flexed 105° (A), extended −60° (B), pronation 20° (C) and supination 40° (D); after the operation, the patient's flexed 120° (E), elbow extended 0° (F), pronation 75° (G) and supination 80° (H)

Fig. 4

The X‐ray of elbow joint of case 1 at 6 months after operation, showing the X‐ray of the elbow joint of Case 1 at 6 months after operation (A: anteroposterior view; B: lateral view)