Review Question - QID 218967

Figure A demonstrates aseptic loosening, most notable about the humeral component. Aseptic loosening is the most common complication in patients who are indicated for a total elbow arthroplasty (TEA) secondary to osteoarthritis.

Total Elbow Arthroplasty (TEA) is an increasingly used motion-preserving modality for the treatment of many debilitating elbow pathologies. Common designs utilized are unconstrained/unlinked components, semi-constrained/linked components, and constrained. Semiconstrained implants have the best longevity and most optimal functional outcomes. Coonrad-Moorey design is an example of a semi-constrained implant. In patients with osteoarthritis, the risk of aseptic loosening of the implants is the most common failure. This is much more of a concern in patients with osteoarthritis than rheumatoid arthritis due to the more active level of demands seen in patients with osteoarthritis. Patients with rheumatoid arthritis are at higher risk of tendon and ligament insufficiency due to the inflammatory nature of their arthritic processes and their effect on soft tissue structures. Infection and periprosthetic fracture are also other concerns but not as much as that of aseptic loosening.

Gill and Morrey provide a 10-15 year follow-up study on 69 patients (78 elbows) who had rheumatoid arthritis that were managed with a Coonrad-Morrey total elbow arthroplasty. They report that at the latest follow-up evaluation, 97% of the elbows were not painful or were only mildly painful, and that the mean arc of flexion-extension was 28 to 131 degrees (an increase of 13 degrees compared with the preoperative value). The mean arc of pronation was 68 degrees, and the mean arc of supination was 62 degrees (an increase of 21 degrees). They further report a 14% rate of complications that required reoperation. They conclude the rate of survival of the prosthesis was 92.4%, with 86% good or excellent and 14% fair or poor results.

Prkic et al. provide a systematic review of the modes of failure of total elbow arthroplasty. A total of 70 articles were included in this systematic review, with 9308 individual total elbow arthroplasties identified with 1253 revisions (13.5%). They report that aseptic loosening was the most prevalent reason for revision (38%), followed by deep infection (19%) and periprosthetic fractures (12%). They conclude that the revision percentage of total elbow arthroplasty for rheumatoid arthritis is significantly higher than for trauma and post-traumatic osteoarthritis and that aseptic loosening was seen less in linked implants.

Figure A is an AP and lateral radiograph demonstrating a loose Coonrad–Morrey humeral component. Note: Complication of early humeral loosening with designs without an anterior flange (this figure demonstrates a design WITH an anterior flange). Figure B is an AP radiograph demonstrating a periprosthetic humerus fracture. Figure C is an AP and lateral radiograph of a semi-constrained implant without any evidence of loosening, fracture, or other complications. Figure D is a clinical photograph of a draining sinus indicative of a postoperative infection, as well as an AP radiograph of a constrained implant. Figure E is a lateral radiograph of a semi-constrained implant with evidence of an olecranon avulsion.

Incorrect Answers:
Answers 2, 4, and 5: Aseptic loosening, and not fracture or infection, is the most common complication in patients who are indicated for a total elbow arthroplasty (TEA) secondary to osteoarthritis.
Answer 3: This is a normal postoperative radiograph of a semi-constrained implant without any evidence of loosening, fracture, or other complications.