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Mid-term Follow-up of Semi-constrained, Linked Total Elbow Arthroplasty in Posttraumatic Conditions
Jenniefer Y. Kho, MD; Brian D. Adams, MD; Howard J. O'Rourke, MD
University of Iowa, Iowa City, IA

Background: Longer term follow-up of total elbow arthroplasty for posttraumatic arthritis (PTOA) or nonunion is limited and is largely underscored by high rate of complications, including bushing wear and loosening. The actual incidence of bushing wear is unknown, as stress views are not routinely performed. Despite this, the revision rate may be lower than what is reported, especially with modern day implants.

Materials & Methods: Sixty-six patients underwent semi-constrained, linked total elbow arthroplasty from 1997-2009 by a single surgeon, of which seventeen were for the treatment of nonunion or PTOA. Retrospective chart review with prospective follow-up was performed. Two were lost to follow-up and one was excluded secondary to dementia. Primary outcome measure was prosthetic survival. Other outcome measures included range of motion, Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire, Mayo Elbow Performance Score (MEPS), overall patient satisfaction, and complications. Stress anteroposterior (AP) radiographs were compared with standard AP elbow views to assess bushing wear, while loosening was evaluated on standard AP and lateral radiographs.

Results: Average age at time of surgery was sixty-six years and minimum follow-up was three years, with an average of 7.6 years. There were no resections or revisions. There was significant improvement in DASH score (p=0.01) and 73% of patients had excellent or good MEPS. All patients except one reported subjective improvement after surgery. There was a trend towards improved range of motion in all directions; supination-pronation arc improved significantly (p=0.008). The DASH and MEPS were no different between the PTOA and non-union groups, although the non-union group had better flexion-extension (p=0.02) and supination-pronation (p=0.04) arcs. Seven out of fourteen patients had a total of eight complications, most commonly related to soft tissue or ulnar neuropathy. Bushing wear was underdiagnosed by five times on standard AP view with an average bushing angle of 5.2 degrees compared to 13.6 degrees on the stress view (p=0.001). Although there was a high incidence of absolute bushing wear (63%), there was no correlation with MEPS (r=-0.20). There was no gross loosening of implants.

Conclusions: Semi-constrained, linked total elbow arthroplasty results in good mid-term functional outcome in patients with post-traumatic conditions. Major complications requiring explant or revision are not as high as reported in the literature with the modern day semi-constrained implant. Bushing wear is common and is likely underdiagnosed up to a factor of five in the absence of stress views, although clinical correlation is unclear.

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