This is a retrospective review of the results of the Acclaim total elbow replacement in 11 older patients aged ≥ 65 years with primary osteoarthritis of the elbow, with a mean follow-up of 57.6 months (30 to 86.4).
Significant reductions in pain and improvement in range of movement and function were recorded. Radiological review revealed two patients with 1 mm lucencies in a single zone, and one patient with 1 mm lucencies in two zones. No components required revision. There were no deep infections, dislocations or mechanical failures. Complications included one intra-operative medial condylar fracture and one post-operative transient ulnar neuropathy, which resolved.
This study demonstrates that the Acclaim prosthesis provides good symptomatic relief and improvement of function in patients with primary osteoarthritis, with low rates of loosening or other complications. This prosthesis can therefore be considered for patients aged ≥ 65 years with primary osteoarthritis of the elbow.
Primary osteoarthritis (OA) of the elbow is relatively uncommon affecting less than 2% of the population, predominantly men undertaking heavy manual work.1 It is characterised clinically by increasing pain, weakness, and loss of movement, particularly extension, and intermittent locking.
Non-surgical management consists of activity modification, analgesics and anti-inflammatories, and physiotherapy.2 Early surgical management involves debridement either by open or more commonly, arthroscopic means.3,4 For end-stage arthritis in patients aged ≤ 65 years distraction interposition arthroplasty has been reported, with modest results and associated complications.5
There is little in the English literature regarding the use of a total elbow replacement (TER) for treatment of primary osteoarthritis. Most TER studies do include a minority of patients with OA, but their results have not been separated from those of post-traumatic OA or rheumatoid arthritis.6–11
Kozak et al2 reviewed five TERs performed for primary OA, using three semi-constrained and two unconstrained prostheses. They reported major complications in four patients, including a fracture of the prosthesis and subluxation, with two patients requiring revision. More recent work by Espag et al12 using the Souter-Strathclyde unlinked prosthesis has, however, reported more positive early results. These authors reviewed ten TERs for primary OA and one for post-traumatic OA, and reported good symptomatic and functional results in all cases at a mean follow-up of 68 months. However, radiological evidence of loosening was noted in three humeral components from 12 months post-operatively, and in two ulnar components, one of which required a revision at 97 months.
The aim of this study was to review our experience with the Acclaim TER (DePuy, Warsaw, Indiana) in patients with primary OA of the elbow.
Patients and Methods
Between 2000 and 2006, 13 patients with a mean age of 65.4 years (51.1 to 80.9) at operation underwent the Acclaim TER for primary OA of the elbow. Two patients died of unrelated causes, leaving 11 (eight men and three women) available for clinical and radiological review. The mean duration of follow-up was 57.6 months (30 to 86.4).
The operation was carried out under general anaesthesia with an axillary nerve block, in a Charnley-Howarth enclosure using body-exhaust suits, with the patient in a lateral decubitus position. Prophylactic intravenous antibiotics were administered at induction. A posterior approach was used, reflecting a tongue of the triceps aponeurosis inferiorly. The ulnar nerve was identified and protected, but not routinely transposed. The radial head was resected in all cases, and the posterior portion of both the medial and the lateral collateral ligaments was released. Humeral and ulnar cuts were made using a combination of a saw and burrs, with appropriate resection guides. After a trial reduction, the humeral component was implanted, pressurising the cement against a cement restrictor after retrograde filling with a gun, a vent and finger pressure. The Acclaim prosthesis has an interchangeable bearing mechanism that allows linked or unlinked modes which can be decided upon intra-operatively. Unlinked prostheses were used in ten cases and linked in one. The skin was closed with clips over two drains and the elbow was splinted in 90° of flexion. Drains were removed after 24 to 48 hours, and the splint, dressings and sutures at ten to 12 days post-operatively. In most cases protected movement began after five days and passive but not active extension was encouraged between two and four weeks postoperatively.
Clinical and radiological review was carried out pre-operatively and annually post-operatively. Objective criteria included pain on a visual analogue score (VAS), range of movement and grip strength. Range of movement was measured with a goniometer, and grip strength using a Jamar dynamometer (Preston, Jackson, Michigan), taking the mean of three measurements. Subjectively, the American Shoulder and Elbow Surgeons (ASES) patient self-evaluation questionnaire13 was used to assess activities of daily living providing a score from 0 to 36, and the Mayo Elbow Performance Index (0 to 100) was calculated post-operatively. The Wrightington method of radiological analysis for the ulna and the humeral components was used to identify prostheses at risk of failure.14 Radiolucencies of 1 mm or greater were recorded.
Statistical analysis was undertaken using the Wilcoxon’s signed-rank test and data was analysed using SPSS version 13 (SPSS Inc., Chicago, Illinois). Statistical significance was set at p < 0.05.
Clinical and radiological review.
At a mean follow-up of 57.6 months (30 to 86.4) all patients had statistically significant improvements in the range of flexion (p = 0.001) from a median of 110° (80° to 135°) to 135° (100° to 150°), and the flexion/extension arc, from a median of 70° (20° to 150°) to 110° (155° to 120°). Extension deficit and grip strength also improved, but did not reach statistical significance. All patients had improved ASES scores, which reached statistical significance (p = 0.001), with the median score increasing from 2 (0 to 29) to 33 (13 to 36) out of 36. Post-operative Mayo elbow performance index scores showed five patients with excellent results (≥ 90), four with good results (75 to 89) and two with fair results (60 to 74). Post-operatively all patients were pain free at rest and at night, with only four reporting mild pain and one moderate pain when at its worst. The remaining six patients were entirely pain free. The results are summarised in Table I⇓.
At the latest radiological follow-up no patients had evidence of frank loosening and eight had no evidence of lucency. Three patients had a 1 mm lucency in humeral zone 5 (lateral projection) and one of these had a second 1 mm lucency in zone 4 of the ulna on the anteroposterior projection (Fig. 1⇓).
One patient had an intra-operative medial condylar fracture, which was managed by suturing the fragment and immobilising the elbow at 90° for three weeks. One patient developed transient ulnar neuritis. No patients developed a wound infection, and none had a dislocation or required a revision procedure.
Traditionally, patients with symptomatic OA of the elbow and failed medical treatment have been managed by either debridement or, in selected cases, interposition arthroplasty.3–5 Debridement is indicated in patients aged < 60 years with impingement and pain at the extremes of movement.1 The arthroscopic method is gaining popularity over the open technique, with comparative studies demonstrating a trend for these patients to have better pain relief, perhaps related to the amount of surgical trauma.15 A recent large study has shown a statistically significant short-term improvement in pain and movement with improved Mayo elbow performance scores.16 Open debridement has been reported as having similar outcomes, with Antuña et al17 finding a mean improvement of 32° in 46 elbows at 6.7 years. However, long-term results of debridement have not proved sustainable, with reports of a loss of movement and worsening of symptoms at eight to 16 years.18
The indications for interposition arthroplasty and TER are similar, both being selected for patients with end-stage OA.1 Interposition has also been used for patients who are young and who may not be suitable for activity limitation.5 Cheng and Morrey5 used this technique in 13 patients with post-traumatic OA and reported only a 62% satisfactory result at five years. Complications were not inconsiderable, with ulnar nerve problems and fascia lata herniation. However, there have been no reports examining the role of interposition arthroplasty in primary OA.
Although there are large and medium-term studies reporting good results following TER in patients with rheumatoid arthritis, little has been written about its use in primary OA.19–22 Currently, TER is indicated in patients aged ≥ 65 years of age, who may have failed with other interventions and who are prepared to accept a certain amount of limitation in the level of their activity.1 The perceived limitations to the use of TER in primary OA have been the risk of loosening and instability in those patients who would usually have better bone stock but impose a higher physical demand on the elbow as compared with patients with rheumatoid arthritis.20
Espag et al12 have reported good short-term results with the use of the unlinked Souter-Strathclyde prosthesis, although five components were radiologically loose and one elbow needed a revision at 97 months. We, in this study, report the largest series of primary OA of the elbow treated with a TER with a complete data set. Our patients had improved function with modest complications. One patient suffered an intra-operative medial condylar fracture. The original humeral resection jigs allowed potentially excessive resection of the supracondylar ridges, thereby predisposing to a fracture. These jigs have subsequently been redesigned. The statistically significant improvement in the flexion arc and the ASES scores are comparable with other studies.2,6,12 In particular, we have found no evidence of loosening or dislocation, which is encouraging. Although our numbers are still relatively small and further medium-term follow-up is necessary, we feel that the results of the Acclaim prosthesis are comparable with those of previous studies and it can therefore be considered for use in patients aged ≥ 60 years with primary OA.21
No benefits in any form have been recieved or will be received from a commercial party related directly or indirectly to the subject of this article.
- Received June 23, 2009.
- Accepted January 26, 2010.
- © 2010 British Editorial Society of Bone and Joint Surgery