International Orthopaedics (SICOT) (1990) 14:315-319 International Orthopaedics

© Springer-Verlag 1990

The Guildford elbow

N. D. Karanjia and P. J. Stiles

The Royal Surrey County Hospital, Egerton Road, Park Barn, Guildford, Surrey, England

Summary. A new unconstrained elbow replacement is described and the results o f 44 primary and 5 re- vision operations assessed. A high incidence o f pain relief (82%) and functional improvement (73%) was achieved. However 23% of primary replacements later underwent loosening as assessed radiologi- cally and 12% have undergone revision for pain. Minor complications not affecting the final result occurred in 28%. The causes and significance of the complications are analysed.

R+sum& Description d'une nouvelle prothOse n o n

contrainte du coude et prbsentation des r~sultats de 44 interventions et de 5 reprises. On a obtenu dans 82% des cas la diminution des douleurs et dans 73% une notable amblioration fonctionnelle. Cependant, aprOs les contr6les radiologiques ultbrieurs, 23% des prothOses prOsentent une image de descellement et 12% ont d~ 6tre reprises pour des phbnomOnes dou- loureux. Des complications mineures ont dtb notbes dans 28% des cas, sans pour autant altdrer le rbsul- tat final. Les causes de ces complications et leur si- gnification sont analysbes.

Introduction

Involvement of the elbow joint in rheumatoid arthritis is common. Symptoms may be controlled by synovectomy and excision of the head of the radius, but this procedure is not effective in late joint disease with advanced erosion of articular

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cartilage and progressive instability [1, 12]. Arth- rodesis is contraindicated in multiple joint invol- vement and excision arthroplasty is unsatisfactory [2, 111.

Total elbow replacement is indicated in a small number of patients with uncontrolled pain from advanced rheumatoid arthritis. It has also been used in the treatment of painful osteoarth- ritis of the elbow. Previous publications show that elbow replacements have a high incidence of complications [5, 8, 9].

This paper describes the use of a total elbow replacement designed and used at the Royal Sur- rey County Hospital, Guildford [3]. The first oper- ation was performed in January 1980.

Material and methods

The prosthesis. The Guildford elbow is a dual component re- placement of the humeroulnar compartment of the elbow, the radial head being excised. It is an unlinked prosthesis and sta- bility depends entirely on the periarticular soft tissues. The humeral component is cast in cobalt-chrome-molybdenum alloy and the ulnar portion is of ultrahigh molecular weight polyethylene. The articular surfaces are based on the normal anatomy of the joint and both components are fixed by in- tramedullary stems with methyl methacrylate cement (Fig. 1 a-d) . The bone excision required for this operation is minimal to allow scope for salvage by a stable excision arthroplasty.

Operative technique. The operation is performed through a posterior approach, the triceps aponeurosis being split longi- tudinally and the incision extended distally to the radial side of the olecranon. The ulnar nerve is identified and mobilised to prevent injury; if necessary it is transposed anteriorly. The radial head is excised. Correct rotational alignment of the ulnar component is aided by the insertion of 2 Kirschner wire markers into the olecranon prior to dislocation. The correct varus/valgus alignment of the humeral component requires precise resection of the lower humerus which is aided by a template placed along the posterior surface of the bone.

316 N. D. Karanjia and P. J. Stiles: The Guildford elbow

36 elbows (82%) were painful at rest, whilst all 44 were painful on movement.

At review 3 elbows (7%) were painful at rest, while 8 (18%) were painful on movement. All painful elbows had either a loose prosthetic com- ponent or subluxed on movement.

Function

This was evaluated using questions on daily activ- ities such as washing, combing hair, doing up shirt buttons, particularly collar buttons, carrying weights and perineal toilet.

Function was improved in 34 arms (73%), un- changed in 6 (14%), and made worse in 2 (4%). The results for 2 elbows were unknown; 1 patient had died immediately after operation and another had been lost to follow up early.

Fig. 1. A Anterior view of humeral and ulnar components; b Lateral view of humeral and ulnar components articulat- ing; C Anterior view of humeral component placed in situ; D Lateral view of ulnar component in situ

Patients. Thirtyseven patients had 44 primary elbow replace- ments inserted between 1980 and 1987, 43 for rheumatoid arthritis and 1 for osteoarthritis. Five revision procedures have been performed, making a total of 49 operations. In all pa- tients the indication for surgery was severe pain. At recent fol- low up 2 patients had died and 1 could not be traced. There were 12 men and 25 women with an average age of 63 years. The follow up period varies from 1 to 8 years, and 30 elbows have been followed for 4 years or more.

All operations were performed by one author (P.S.), and an independent assessment made by the other (N.D.K.). The patients were assessed regarding pain and arm function. The range of flexion, extension, pronat ion and supination was measured using a goniometer. Anteroposterior and lateral radiographs were taken sequentially during the period of fol- low up and at the final review.

Results

Pain

Pain was subjectively assessed as either present or absent at rest or on movement. Before operation

Movement (Figs. 2 and 3)

The average range of flexion and extension before operation was 44°-126 ° and postoperatively 38°-134 °. A range of 100 ° was achieved in 28 (64%), whilst the functionally important range of 30°-130 ° [7], was achieved in 16 (37%). Full flex- ion was present in 32 elbows (73%). Extension was improved in 26 elbows (60%) but was never full. From the neutral position an average of 67 ° of pronation and 54 ° of supination was possible pre- operatively, a range of 121 °. After operation an average of 75 ° of pronation and 58 ° of supination was possible, a range of 133 °. Thus an improve-

Flexion and Extension 90 o

Pro 4 4 ° S " I ""%.P re 126° Post 380 L " ~ 1 .,,"" "}. Post 134 °

Fu. ox,oos,on 0°[ 180° Fu..exion Hand Elbow Shoulder

Fig. 2. Flexion and extension ranges before and after total elbow replacement

Pronation and Supination 90 °

o / / I - - .......... .. Pre-op 54 Pre-op 67 °

Post-op 5 8 ~ . ~ \ . 133 ° t ...... / ~ , Post-op 75 °

Full supination 90°i ,.~90 ° Full pronation Axis of Rotation

Fig. 3. Rotational ranges before and after total elbow replace- ment

N. D. Karanjia and P. J. Stiles: The Guildford elbow 317

One patient died within 24 h of operation fol- lowing a myocardial infarction.

(I) Olecranonfracture (Fig. 6). One occurred at the time of operation in a patient with poor bone stock. The ulnar component of this elbow loos- ened 2 years after insertion. The second followed a forced flexion injury 3 months after operation but despite persistent non-union there has been no loosening of this ulnar component with excel- lent pain relief and function.

(II) Delayed wound healing. No major problems of wound healing occurred. Superficial dehis- cence occurred in 6 elbows. In 2 of these patients an olecranon bursa had been found at operation. One bursa resulted in a persistent sinus which was explored and curretted before healing occurred. There was no case of major skin loss.

Fig. 4. Anteroposterior radiograph of prosthesis in situ

Fig. 5. Lateral radiograph of prosthesis in situ

ment of 12 ° of rotation occurred. Full pronation was present in 18 (41%) assessed, and full supina- tion in 5 (l 1%). A range of 100 ° of rotation was achieved in 37 elbows (84%), whilst the function- ally important range of at least 50 ° of pronation together with at least 50 ° of supination [7] was present in 24 elbows (55%). Those patients with significant residual restriction of rotation had arthritic involvement of the inferior radioulnar joint.

(lII) Deep infection. No bacteriologically proven infections occurred but a chronic sinus developed in one elbow following a revision procedure. This necessitated complete removal of the prosthesis and cement leaving the patient with a pseudoarth- rosis. No organism was ever grown from the tissue biopsy at revision, nor from the preceding discharging sinus. Infection must however be presumed in this elbow.

(IV) Ulnar nerve symptoms. These occurred in 9 patients. Only 2 (4%) had major permanent ulnar nerve damage, whilst the remainder had transient or permanent mild sensory symptoms.

Radiography (Figs. 4 and 5)

Standard anteroposterior and lateral radiographs were taken at follow up. Particular reference was paid to the position of the stems with respect to the cortices of the bones, and sequential films compared. Radiolucent cement was used in most patients and the assessment of loosening could only be made by comparing films for movement of the prosthesis or bone erosion. Wrist radio- graphs confirmed that rheumatoid disease af- fected 24 wrists (55%).

(V) Subluxation/Dislocation. This occurred in 5 el- bows (11%). Early subluxation/dislocation oc- curred within four weeks of operation in 3 elbows in the first year of the replacement programme when immediate postoperative mobilisation was routine. Posterior subluxation on extension oc-

Complications

A total of 44 primary procedures and 5 revision operations have been performed.

The major long term complication of loosen- ing affected 10 elbows (23%). A further 32% had minor or transient complications at or soon after operation but not affecting the final result. Fig. 6. Olecranon fracture complicating total elbow replace-

ment

318 N .D . Karanjia and P. J. Stiles: The Guildford elbow

curred in one and complete posterior dislocation in two; the first has recently been noted as having loosening of the ulnar component. These 3 elbows stabilised following a 4 week period of immobili- sation in a backslab. Late subluxation/ disloca- tion occurred in 2 elbows. One started to sublux medially 18 months after operation and was asso- ciated with loosening of the humeral component. There had been no injury. The other had 2 revi- sion procedures prior to permanent posterior dis- location. Both elbows have an excellent range of movement but this is associated with intermittent pain.

(VI) Loosening and revision (Fig. 7). The fate of 10 elbows (23%) with loosening of the prosthesis is shown in Fig. 7. The humeral component alone loosened in 6, the ulnar alone in 2 and both in 2. The time to loosening varied from 7 months to 6 years, with an average of 18 months.

Two elbows have been revised once; in these only the humeral component was loose and a long stemmed prosthesis inserted at revision.

One elbow in which both components loos- ened has been revised once, but subsequently be- came infected, necessitating the removal of both components leaving a pseudoarthrosis.

The second elbow in which both components loosened subsequently required a further revision for a loosened ulnar component. This elbow has since dislocated though it has a good range of movement with only intermittent pain.

Discussion

The selection of patients for total elbow replace- ment must be undertaken with careful regard for the place of conservative surgery. Synovectomy,

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Fig. 7. Bar chart showing the fate of 10 elbow replacements that underwent clinical loosening

with or without excision of the radial head gives symptomatic improvement in 70% of patients for up to 5 years after operation [6, 12].

The main objectives of the Guildford elbow replacement are to relieve pain and retain mo- bility in advanced disease. Assessment of function following total elbow replacement is complex due to the fact that most patients have involvement of other joints in the same limb, producing a cumu- lative functional limitation. In common with oth- ers we have demonstrated that immediate post- operative relief of pain can be achieved in 100% of patients, and that the range of movement is usually increased. A full range of flexion was achieved in over 70%, but some residual limita- tion of extension was always present. Limited ex- tension has been noted with all elbow arthroplas- ties and with other prostheses a loss of extension has been common [4, 9]. Improvement in exten- sion in this series was probably due to the use of the triceps splitting approach in preference to the standard detachment of a distal flap. In the ma- jority of patients forearm rotation was improved, and persistent significant limitation of rotation could be attributed to arthritis of the inferior radio-ulnar joint (55%).

Functional analysis shows that the average person needs 30-130 ° of flexion and 50 ° each of pronation and supination in order to accomplish day to day tasks [7]. A 100 ° range of flexion/ex- tension and rotation was achieved in 64%, and the majority (73%) of patients were satisfied with their improved function.

All previous reports of elbow prostheses have shown a high incidence of complications. Johnson, Getty and Lettin in 1984 [4], reporting on 50 replacements using the Stanmore prosthe- sis, quoted a 61% complication rate. Lowe et al. [5] in 1984 assessed 47 elbow replacements over 8 years, quoting a 36% revision rate for their condy- lar unconstrained and later stemmed prostheses. The total incidence of loosening was not men- tionned nor the total complication rate. Soni and Cavendish [10] in 1984 described 80 uncon- strained Liverpool elbow prosthetic replacements over 8 years, with an overall complication rate of 75%.

In our series the major complication of loos- ening was radiologically apparent in 23% of el- bows, whilst a further 32% suffered a minor or transient complication not affecting the final re- sult. At long term follow up over 70% were free of complications.

The only major intraoperative complication occurred in one patient in whom the grossly

N. D. Karanjia and P. J. Stiles: The Guildford elbow 319

eroded and osteoporotic olecranon was fractured, subsequently leading to loosening of the ulnar component. No bacteriologically proven infection occurred and wound healing was not a significant problem, unlike with other prostheses [4, 9]. Our findings suggest that any associated olecranon bursa should be carefully removed.

Ulnar nerve symptoms immediately following operation were common (20%) and this was also noted by Soutar in a communication at the S.I.C.O.T. meeting, Munich 1987. This complica- tion may be due to excessive mobilisation of the nerve affecting its blood supply or to traction on a taped nerve during the operation. We feel that simple decompression with minimal mobilisation is preferable to anterior transposition.

Dislocation is a risk with any unconstrained elbow prosthesis which relies on the intact capsule and collateral ligaments for stability. The factors of importance are the tension of the capsule and ligaments, the alignment of the components and the rigor of postoperative mobilisation. In our se- ries dislocation occurred in 11% of elbows. The causative factors include early mobilisation, mal- rotation of the ulnar component, excessive valgus of the humeral component, excessive preoperative instability and loosening.

Three early dislocations occurred in patients when immediate mobilisation was undertaken. Since the routine has been changed to a l0 day period of rest in plaster followed by progressive mobilisation, there have been no cases of early in- stability and no reduction in the final range of movement.

Late dislocation/subluxation is difficult to treat, and occurred in 2 elbows. Both have an ex- cellent range of movement and, although inter- mittent pain is experienced, the symptoms do not justify operation at present. We believe that insta- bility can be avoided if grossly unstable joints are rejected, provided that the components are cor- rectly aligned, the ligaments correctly tensed by adjusting the depth of insertion of the humeral component in the bone, or by reconstructing the ligaments and immobilising the elbow for 10 days.

It is clear that loosening of one or both com- ponents is a major problem with all prostheses. Lowe et al. [5] from Northwick Park reported their revision rate for loosening was 36%. Johnson, Getty and Lettin [4] report a 20% in- cidence of loosening for the Stanmore elbow. Roper et al. [9] from the London Hospital, de- scribed an unconstrained elbow with a 27% major failure rate. This problem is undoubtedly due to the osteoporotic bone in patients with advanced rheumatoid disease.

In our series radiological evidence of loosen- ing was present in 10 elbows (23%).

Loosening of the humeral component is the major problem, and factors involved probably in- clude a disproportion between the size of the prosthesis and the patient's bone, excessive re- moval of the posterior cortex of the humerus, in- adequacies of cement introduction at operation and trauma following discharge.

All loose humeral components show a similar pattern with the stem tilting forwards, the tip often eroding the anterior cortex. This suggests that more adequate fixation of the articular part of the prosthesis within the condyles is required to overcome the forces that tend to tilt the prosthesis.

Factors leading to loosening of the ulnar com- ponent include fracture of the olecranon at opera- tion, disproportion between the stem of the pros- thesis and bone, cement filling deficiencies and again postoperative trauma. The indication for re- vision is pain together with radiological evidence of loosening of a component.

References

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2. Dickson RA, Stein H, Bentley G (1976) Excision arthro- plasty of the elbow in rheumatoid disease. J Bone Joint Surg 58:227-229

3. Evans EJ, Stiles PJ (1980) The Guildford Elbow Joint. J Biomed Engineering 2:205-210

4. Johnson JR, Getty CJM, Lettin AWF, Glasgow MMS (1984) The Stanmore total elbow replacement for rheuma- toid arthritis. J Bone Joint Surg 66:732-736

5. Lowe LW, Miller AJ, Allure RL, Higginson DW (1984) The development of an unconstrained elbow arthroplasty: a clinical review. J Bone Joint Surg 66: 243-747

6. Marmor L (1972) Surgery of the rheumatoid elbow; Fol- low up study on synovectomy combined with radial head excision. J Bone Joint Surg 54:573-578

7. Morrey BF, Askew LJ, An KN, Chao EY (1981 a) A bio- mechanical study of normal functional elbow motion. J Bone Joint Surg 63 : 872-877

8. Morrey BF, Bryan RS, Dobyns JH, Linscheid RL (1981) Total elbow arthroplasty; a five year experience at the Mayo Clinic. J Bone Joint Surg 63:1050-1063

9. Roper BA, Tuke M, O'Riorden SM, Bulstrode CJ (1986) A new unconstrained elbow; a prospective review of 60 replacements. J Bone Joint Surg 68:566-569

10. Soni RK, Cavendish ME (1984) A review of the Liverpool elbow prosthesis from 1974-1982. J Bone Joint Surg 66: 248-253

11. Souter WA (1973) Arthroplasty of the elbow with particu- lar reference to metallic hinge arthroplasty in rheumatoid patients. Orthop Clin North Am 4:395-413

12. Taylor AR, Mukerjee SK, Rana NA (1976) Excision of the head of the radius in rheumatoid disease. J Bone Joint Surg 58:485-487