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The Journal of Bone and Joint Surgery 81:38-47 (1999)
© 1999 The Journal of Bone and Joint Surgery, Inc.

Instability of the Elbow Treated with Semiconstrained Total Elbow Arthroplasty*

MATTHEW L. RAMSEY, M.D.{dagger}, ROBERT A. ADAMS, R.P.A.{ddagger} and BERNARD F. MORREY, M.D.{ddagger}, ROCHESTER, MINNESOTA

Investigation performed at the Mayo Clinic and Mayo Foundation, Rochester


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
The results of nineteen semiconstrained modified Coonrad-Morrey total elbow arthroplasties performed in nineteen patients to treat instability were evaluated at an average of seventy-two months (range, twenty-five to 128 months) postoperatively. Preoperatively, all patients had either a flail elbow or gross instability of the elbow that prevented useful function of the extremity. The instability of sixteen elbows was the result of a traumatic injury or of the treatment of such an injury. The most recent result was satisfactory for sixteen elbows and unsatisfactory for three. The average overall Mayo elbow performance score increased from 44 points preoperatively to 86 points postoperatively. At the most recent follow-up examination, no elbow was unstable. The average arc of flexion was from 25 degrees (range, 0 to 60 degrees) to 128 degrees (range, 30 to 142 degrees), which represented a 58-degree increase from the preoperative average arc. Sixteen patients had little or no pain after the arthroplasty. There were four complications In four patients. Three complications (loosening of the humeral component in one patient and a fracture of the ulnar component in two) occurred postoperatively; all three were treated with a revision procedure. The other complication (a fracture of the olecranon) occurred intraoperatively and was treated with tension-band fixation; the most recent outcome was not affected. Radiographically, one patient had complete (type-V) radiolucency about the humeral component. None of the nine patients for whom true anteroposterior radiographs were available had evidence of wear of the bushings. The bone graft behind the anterior flange of the humeral prosthesis was mature in fourteen elbows, incomplete in two, and resorbed in two. One patient was excluded from this analysis because radiographs were not available. Instability of the elbow resulting in the inability to use the extremity is a challenging clinical situation. However, in patients who are more than sixty years old and in selected patients who are less than sixty years old but who have extensive loss of bone as a result of severe injury, have had multiple operations, or have rheumatoid arthritis, total elbow arthroplasty with a linked, semiconstrained prosthesis reestablishes a mobile, stable joint without premature loosening or failure of the components. In our experience, the use of customized implants, maintenance of the muscular attachments to the epicondyles, and reconstruction of the epicondyles to the implant were unnecessary.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
The elbow joint serves as a fulcrum through which the muscles of the upper extremity exert their effects. Normal use of the upper extremity allows the hand to be positioned in space and requires a well functioning elbow joint. Loss of a stable fulcrum due to destruction of the elbow can result in a functionally useless extremity. In the most extreme circumstance, destruction of the elbow leads to a flail extremity. If the destruction is less severe, stability can be maintained when the arm is adducted against the body. However, during activities that require the arm to be away from the body, the fulcrum for stable motion of the elbow is not able to withstand the forces across the elbow, resulting in gross instability.

Instability of the elbow leading to a functionally useless extremity is a challenging clinical situation that can result from nonunion of a supracondylar or intracondylar fracture or of a fracture of the medial or lateral epicondyle, severe rheumatoid destruction of the humerus, loss of bone following severe trauma, or excision of bone for the treatment of infection. Operative treatment may include open reduction and internal fixation with bone-grafting,1,4,11,12, reconstruction with an allograft1,2,20,21 arthrodesis10, and total elbow arthroplasty5,7,12,14,16.

The early results of total elbow arthroplasty with constrained or custom implants to treat instability have been disappointing because of the high rate of complications7,12. However, because function can be greatly improved when failure is avoided, we reviewed our experience with this difficult problem5,14,16. The purpose of the present study was to evaluate the results of treatment of grossly unstable and flail elbows with semiconstrained total elbow arthroplasty as well as to evaluate the mechanical performance of the implant.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
We reviewed the records of twenty-one consecutive patients who had had a total elbow arthroplasty with a noncustom modified Coonrad-Morrey prosthesis (Zimmer, Warsaw, Indiana) inserted with cement, between November 1983 and February 1994, to treat instability of the elbow. The results for these patients have not been reported previously. A minimum duration of follow-up of two years was required for inclusion in the study. Two patients had died, of causes unrelated to the procedure, less than two years postoperatively and were therefore excluded. Thus, the results of nineteen total elbow arthroplasties in nineteen patients were available for review. The average age of the two men and seventeen women at the time of the procedure was sixty-one years (range, twenty-two to eighty-one years).

In fourteen patients, who were an average of sixty-six years old (range, fifty-two to eighty-one years old), an unstable nonunion of a fracture of the distal end of the humerus had resulted in a functionally useless elbow. The initial treatment for this group had included open reduction and internal fixation (eleven patients), irrigation and débridement with external fixation for an open injury (one), and immobilization in a cast (two). An average of 2.3 operations (range, zero to nine operations) had been performed before the total elbow arthroplasty. Total elbow arthroplasty was considered for these patients because of their age, their limited activity level, the failure of a previous operation, poor bone quality, or inadequate bone stock for fixation of the distal fragment. All but one patient were at least sixty years old; the patient who was less than sixty years old (Case 16) had had nine previous operations in an attempt to obtain union of a supracondylar fracture, and there was not sufficient distal humeral bone stock for another attempt at internal fixation.

The remaining five patients, who were an average of forty-six years old (range, twenty-two to fifty-seven years old), had bone loss due to a variety of causes. Two patients who had severe rheumatoid involvement of the elbow had extensive erosion of the distal end of the humerus, resulting in a fracture of a thin medial epicondyle. One patient had a severe crush injury to the elbow with traumatic loss of bone at the distal end of the humerus and the olecranon, and one patient had a resection of the distal end of the humerus following chronic infection at the site of a supracondylar nonunion.

The indication for the procedure in all patients was instability of the elbow that prevented useful function of the extremity. Nine patients had a flail elbow (Fig. 1-A), and the remaining ten had a grossly unstable elbow (Fig. 1-B). Two patients had no pain, nine had mild pain, and eight had moderate pain. No patient had severe pain, and pain was not the primary indication for any of the arthroplasties.



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  		FIG1-A: Fig. 1-A Anteroposterior radiographs of a flail elbow (Fig. 1-A) and a grossly unstable elbow (Fig. 1-B) after a fracture of the distal end of the humerus. Instability can develop without any previous operative procedure or after multiple attempts to achieve union.

 


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  		FIG1-B: Fig. 1-B Anteroposterior radiographs of a flail elbow (Fig. 1-A) and a grossly unstable elbow (Fig. 1-B) after a fracture of the distal end of the humerus. Instability can develop without any previous operative procedure or after multiple attempts to achieve union.

 

Operative Technique
The technique for insertion of a semiconstrained elbow replacement for treatment of nonunion of the distal end of the humerus has been described elsewhere15-17. However, several important points should be emphasized. The triceps was released in continuity with the ulnar periosteum and the fascia of the forearm3 in the first ten patients. A triceps-sparing approach in which the insertion of the triceps remained intact was used in the last nine patients. The latter approach is currently favored when the distal humeral bone stock is absent or the distal end of the humerus is to be resected at the time of the procedure15-17. Because the insertion of the triceps is left intact, unrestricted motion can be initiated in the immediate postoperative period. When distal humeral bone stock is present and the distal end of the humerus is not going to be resected at the time of the procedure, a triceps-sparing approach is not possible. In this situation, a triceps-reflecting approach is preferred.

The ulnar nerve was translocated anteriorly at the time of the arthroplasty in ten patients and had been translocated anteriorly during a previous procedure in the remaining nine. If the location of the nerve was known in a patient who had had a previous transposition, the nerve was not identified by formal dissection at the time of the arthroplasty. If the location of the nerve was not known, the nerve was identified and protected. Dissection of the nerve can be extremely difficult if it was manipulated during a previous procedure or if there is extensive scarring of the nerve at the site of a nonunion.

A long-standing flail elbow can result in a foreshortened extremity due to soft-tissue contracture (Fig. 2). Rigid soft-tissue contracture about a foreshortened limb may necessitate removal of additional bone from the distal end of the humerus so that the components will articulate without placing undue tension on the soft tissues. The humerus can be shortened by as much as two centimeters proximal to the roof of the olecranon fossa, in order to achieve articulation of the components and to gain an acceptable range of flexion (at least from 30 to 130 degrees), without markedly weakening the triceps. The goal of this procedure is full unrestricted motion if this is possible without resecting more than two centimeters of the humerus. The ulnar component is inserted first with use of an intramedullary cement-injecting system and tobramycin-impregnated polymethylmethacrylate. The common flexors and extensors are sutured to the triceps fascia to provide an anchor point for these muscle groups and to restore the muscular sleeve of tissue about the implant. No cast or splint is needed in the immediate postoperative period.



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  		FIG2: Fig. 2 Radiograph demonstrating gross instability of the forearm referable to the brachium, which is a major problem after operative resection of bone. This condition places increased stresses on the bone-cement interface as well as on the articulation after an elbow arthroplasty.

 

Implant
The design of the modified Coonrad-Morrey implant makes it ideal for use when there is a loss of bone at the distal end of the humerus. The axis of rotation of the implant is coincident with the native axis of rotation. The reference for reestablishing the axis of rotation is the depth of insertion of the implant relative to the roof of the olecranon fossa, not relative to the joint line. Therefore, the axis is restored even if there is an osseous defect in the roof of the olecranon fossa (Fig. 3). In fact, shortening of the humerus as much as two centimeters proximal to the olecranon fossa (four to five centimeters of distal humeral bone loss) is acceptable with this implant, which obviates the need for a custom device6,19.



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  		FIG3: Fig. 3 Photographs showing the components of the Coonrad-Morrey elbow prosthesis, which allows the axis of rotation to be reestablished in the absence of distal humeral bone stock as far proximal as the roof of the olecranon fossa. The medial and lateral epicondyles are not necessary for stability of the implant because the anterior flange provides rotational stability.

 

Evaluation of the Patients
The Mayo elbow performance score14 was used to document subjective, objective, and functional characteristics before and after the arthroplasty. The performance index consists of scores for pain (maximum score, 45 points), motion (maximum score, 20 points), stability (maximum score, 10 points), and activities of daily living (maximum score, 25 points). A postoperative score of 90 to 100 points indicates an excellent result; a score of 75 to 89 points, a good result; a score of 60 to 74 points, a fair result; and a score of less than 60 points, a poor result.

Radiographic Evaluation
Bone loss was graded according to the amount of distal humeral bone stock that was absent before the procedure (in the patients who had bone loss) or according to the size of the defect that was created after excision of the ununited segment at the time of the procedure (in the patients who had a nonunion)13. Grade-1 bone loss indicated damage to the articular surface but an intact trochlea and capitellum; grade-2, absence of the trochlea but intact medial and lateral epicondyles; grade-3, absence of either the medial or the lateral epicondyle; and grade-4, loss of bone from or operative resection of the medial and lateral epicondyles to or proximal to the level of the olecranon fossa.

Postoperative radiographs were evaluated for incorporation of the bone graft behind the anterior flange of the prosthesis, for progressive radiolucency about the bone-cement interface, and for evidence of wear of the bushings. The bone graft was classified as resorbed if it was not seen on the most recent radiographs, as incomplete if it was seen on the most recent radiographs but was not incorporated in the anterior cortex of the distal end of the humerus, and as mature if it was incorporated in the anterior cortex of the distal end of the humerus with trabeculation and hypertrophy.

Radiolucency was evaluated by comparing the immediate postoperative anteroposterior radiographs with the most recent anteroposterior radiographs. Progressive radiolucency was classified as none, type I (a progressive radiolucent line less than one millimeter wide that involved less than 50 percent of the bone-cement interface), type II (a progressive radiolucent line at least one millimeter wide that involved less than 50 percent of the interface), type III (a progressive radiolucent line more than one millimeter wide that involved at least 50 percent of the interface), type IV (a progressive radiolucent line more than two millimeters wide around the entire bone-cement interface), or type V (a progressive radiolucent line more than two millimeters wide around the entire bone-cement interface with shifting of the component).

Wear of the bushings was evaluated on a true anteroposterior radiograph of the prosthesis made at the most recent follow-up evaluation. A line was drawn parallel to the yoke of the humeral component, and another line was drawn parallel to the medial or lateral surface of the ulnar component (Figs. 4-A and 4-B). The prosthesis has about 7 degrees of varus-valgus and axial rotational laxity. An angle of intersection of more than 7 degrees between these two lines is indicative of excessive tolerance of the bushings due to wear or plastic deformation.



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  		FIG4-A: Figs. 4-A and 4-B: On a true anteroposterior radiograph, a qualitative determination of wear of the bushings may be estimated by observing the angular relationship between the ulnar component and the humeral yoke. Fig. 4-A: A normally aligned implant.

 


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  		FIG4-B: Fig. 4-B: Wear of the bushings six years postoperatively.

 

Statistical Analysis
The significance of preoperative and postoperative continuous and discrete variables was assessed with a one-tailed t test. A p value of less than 0.05 was considered significant.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
The average duration of follow-up was seventy-two months (range, twenty-five to 128 months) (Table I). On the basis of the overall Mayo elbow performance score, the result was satisfactory for sixteen elbows at the most recent follow-up evaluation: ten elbows had an excellent result, and six had a good result. The remaining three elbows had an unsatisfactory (fair or poor) result. Three elbows were revised. The revision procedure adversely affected the most recent outcome for two of these elbows, and the index procedure was considered a failure.


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  		TABLE I DATA ON THE PATIENTS

 
The average preoperative Mayo elbow performance score was 44 points (range, 20 to 80 points) compared with 86 points (range, 60 to 100 points) at the time of the most recent follow-up. This represents a significant improvement in overall function (p < 0.001).

Stability
Before the procedure, all patients had instability that prevented useful function of the elbow (a Mayo elbow performance score for stability of 0 points). No patient had instability postoperatively (Figs. 5-A and 5-B).



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  		FIG5-A: Figs. 5-A and 5-B: Radiographs of the flail elbow shown in Fig. 1-A, made five years postoperatively. Fig. 5-A: There are no adverse changes at the bone-cement interface.

 


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  		FIG5-B: Fig. 5-B: The bone graft behind the flange is incorporated.

 

Range of Motion
All nineteen patients had a functionally useless range of motion preoperatively. All nine patients who had a flail elbow had a preoperative Mayo elbow performance score of 0 points for range of motion. The ten patients who had gross instability of the elbow generally had sufficient stability in the sagittal plane with the arm adducted against the body to allow active motion. The average preoperative arc of active flexion of the ten grossly unstable elbows was from 26 degrees (range, 0 to 45 degrees) to 113 degrees (range, 90 to 135 degrees), an arc of 87 degrees. The average postoperative arc of active flexion of these elbows was from 19 degrees (range, 0 to 40 degrees) to 131 degrees (range, 90 to 140 degrees), an arc of 112 degrees and an increase of 25 degrees compared with the preoperative arc. The average postoperative arc of active flexion for the nine patients who had had a flail elbow was from 32 degrees (range, 0 to 60 degrees) to 126 degrees (range, 30 to 142 degrees), which represents an overall increase of 94 degrees. The overall average postoperative arc of active flexion was from 25 degrees (range, 0 to 60 degrees) to 128 degrees (range, 30 to 142 degrees), a significant (58-degree) improvement compared with the preoperative arc (p < 0.001).

Pain Relief
The average score for pain was 25 points (range, 15 to 45 points) preoperatively and 37 points (range, 15 to 45 points) at the most recent follow-up examination (p < 0.002). At the time of follow-up, twelve patients had no pain, four had mild pain, and three had moderate pain. No patient had severe pain either before or after the procedure.

Activities of Daily Living
The ability to perform activities of daily living was assessed for sixteen patients preoperatively and for all nineteen patients postoperatively. It was found to be severely limited by the instability preoperatively, with an average score of 7 points (range, 0 to 25 points). The average score was 22 points (range, 0 to 25 points) postoperatively (p < 0.001).

Radiographic Evaluation
The preoperative radiographs were evaluated for the degree of bone loss. One patient had grade-3 bone loss with fracture of the medial epicondyle, and eighteen had grade-4 bone loss as far as or proximal to the roof of the olecranon fossa.

Anteroposterior and lateral radiographs of eighteen patients were evaluated for incorporation of the graft at an average of forty-nine months (range, twenty-four to 104 months) postoperatively. One patient was excluded from the analysis because the only radiographs available had been made four months postoperatively. The bone graft was resorbed in two patients, incomplete in two, and mature in fourteen.

Adequate postoperative radiographs of fifteen patients were available for the evaluation of progressive radiolucency. Fourteen patients did not have any progressive radiolucency. The remaining patient had type-V progressive radiolucency at the bone-cement interface that necessitated revision of the humeral component.

A true anteroposterior radiograph of the yoke of the humeral component was available for the assessment of wear of the bushings (as evidenced by an angle of intersection of more than 7 degrees) in nine patients at an average of fifty-three months postoperatively. No patient had wear of the bushings.

Complications
There was one intraoperative complication and three postoperative complications in four patients. The intraoperative complication was a fracture of the olecranon in a patient who had severe rheumatoid involvement of the elbow with marked erosion of the olecranon. The fracture was effectively treated with tension-band wiring after the components were implanted. The three postoperative complications included loosening of a humeral component and fracture of two ulnar components. One ulnar component fractured as the patient was lifting 100-pound (forty-five-kilogram) bags of animal feed. The other ulnar component fractured when the patient fell.

The three postoperative complications necessitated a revision. At the time of the revision of the humeral component, the tissues were found to be blackened from metallic debris. Inspection of the component demonstrated delamination of the plasma-sprayed titanium surface preparation. The most recent result was excellent for one elbow and fair for two. The procedures in the two elbows that had a fair result were considered failures. The most recent result was good for the elbow that had an intraoperative fracture but did not need an additional operation.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
To the best of our knowledge, there are virtually no reports in the literature on the treatment of instability of the elbow with total elbow arthroplasty. Limited information has been reported for larger series of patients who had posttraumatic osteoarthritis, rheumatoid arthritis, or nonunion of the distal end of the humerus5,7,13,14,16. However, in each of those series, the primary indication for the operation was pain in the elbow. In the present series, the principal indication was instability that prevented useful function of the elbow. The elbow was flail or grossly unstable when functional activities were attempted. Treatment of an unstable elbow with total elbow arthroplasty reestablishes stability by realigning the limb by means of the implant.

Open reduction and internal fixation with autogenous bone-grafting has been the treatment of choice for established nonunion of the distal end of the humerus1,4,11,12. In patients who are less than sixty years old, every effort should be made to preserve bone stock and to obtain union with this method1,11. Advanced age, a limited level of activity, distal humeral bone loss, and irreversible damage of the articular surface of the ununited segment have been mentioned as contraindications to additional attempts at obtaining union11. The average age of the fourteen patients in our study who had a nonunion of the distal end of the humerus was sixty-six years. In an elderly patient who has osteopenia of the distal fragment and abnormalities of the articular cartilage, open reduction and internal fixation and mobilization of the joint is not likely to be successful, even if the patient has not had a previous operative attempt at achieving union. The only patient who was younger than sixty years and had a nonunion of the distal end of the humerus in our study had had nine previous attempts at achieving union, which was no longer possible because of insufficient bone stock.

The options for the management of patients who have bone loss at the distal end of the humerus are limited. Arthrodesis of the elbow is designed to relieve pain and restore stability. While successful fusion is possible in an extremity with bone loss, it is difficult to achieve when the bone stock is substantially deficient10. In addition, arthrodesis of the elbow markedly limits the ability to perform many activities of daily living18. Allograft reconstruction of the distal end of the humerus has been used in patients who were thought to be too young for arthroplasty1,20,21 and who had traumatic bone loss about the elbow2. However, serious complications, including nonunion of the allograft-host junction and resorption of the allograft, have prevented widespread use of this method1,20. The senior one of us (B. F. M.) believes that the results of allograft reconstruction are too unpredictable for him to recommend its use in patients who are more than fifty-five to sixty years old.

In the present study, all five of the patients who had severe bone loss at the distal end of the humerus were less than sixty years old. Three of these patients had long-standing rheumatoid arthritis, and this factor weighed heavily in the decision to perform a total elbow arthroplasty. The distal end of the humerus was completely absent in the other two patients. The decision to perform a total elbow arthroplasty in these patients was based on the lack of alternative reconstructive options and the fact that the functional improvements that are possible with arthroplasty are superior to those that can be achieved with arthrodesis or allograft reconstruction. We recognize that younger patients who place high demands on the elbow may need a revision in the future. However, the use of total elbow arthroplasty in these patients does not preclude a subsequent revision total elbow arthroplasty, arthrodesis, or allograft reconstruction8,9.

When a stable fulcrum for motion of the elbow has been lost, total elbow arthroplasty reestablishes alignment of the upper extremity by way of articulation of the humeral and ulnar components. Forced articulation of the humeral and ulnar components against a contracted soft-tissue envelope risks damage to the neurovascular status of the extremity, may affect the ultimate range of motion, and places increased stress on the bone-cement interface. Total elbow arthroplasty performed to treat an unstable elbow results in an extreme clinical situation in which high mechanical demands are placed on the implant. Repair of the common flexor and extensor muscle masses to the triceps fascia provides an anchor point for these muscles and may reduce the stress on the implant and the bone-cement interface.

Concerns about the long-term performance of the implants prompted a radiographic review in which we looked for evidence of mechanical failure. A true anteroposterior radiograph of the humeral yoke is necessary to assess wear of the bushings. Such a radiograph was available for only nine patients in the present study. In addition, these were not stress radiographs. Thus, the true degree of wear might have been underestimated. The fact that no patient needed revision of the bushings by an average of seventy-two months supports the conclusion that the bushings function for at least a medium duration.

One patient had type-V progressive radiolucency about the bone-cement interface evident two years postoperatively; this patient was found to have delamination of the plasma-sprayed titanium surface preparation from the humeral implant at the time of a revision procedure. This prompted a change to a beaded titanium surface preparation, and there were no more problems.

The ulnar component fractured in two patients. One patient was performing activities that placed the implant at risk, and the other patient fell. While a fracture of a component is a catastrophic event, the fact that these patients could be active and were not limited by pain or instability attests to the success of the procedure. In both patients, the fracture occurred near the junction between the surface preparation proximally and the smooth part of the component distally. This was thought to be a potential source of stress concentration that predisposed to fracture. The ulnar implant has since been redesigned: it is now smooth, with a polymethylmethacrylate precoat surface preparation. To our knowledge, no fractures of the ulnar component have been reported since this change.

Since 1981, we have used a noncustom semiconstrained total elbow prosthesis with repair of the common flexor and extensor muscles to the triceps fascia in all patients who have a flail or grossly unstable elbow. The use of custom implants, maintenance of the common flexor and extensor muscle attachments to the epicondyles, and reconstruction of the medial and lateral epicondyles to the implant to treat this condition have been advocated by some authors5,7. In our experience, such measures have been unnecessary.

While a flail or grossly unstable elbow presents many difficult challenges, the outcome of the procedure that we described is rewarding. Preoperatively, these patients have a useless extremity that cannot be effectively positioned in space. Reestablishment of a stable fulcrum for motion of the elbow with an arthroplasty creates a functional extremity.

NOTE: The authors express their appreciation to Michael Morrey, Ph.D., for his assistance with the statistical analysis.


   Footnotes
 
*One or more of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

{dagger}Shoulder and Elbow Service, Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 2 Silverstein Pavilion, Philadelphia, Pennsylvania 19104.

{ddagger}Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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