Elbow arthroplasty for advanced inflammatory elbow disease—rheumatoid arthritis and pigmented villonodular synovitis

doi:10.21203/rs.3.rs-2001044/v1

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Elbow arthroplasty for advanced inflammatory elbow disease—rheumatoid arthritis and pigmented villonodular synovitis

https://doi.org/10.21203/rs.3.rs-2001044/v1

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Background

Total elbow arthroplasty is the treatment for end-stage elbow disease. In contrast to severe fractures and degenerative disease, inflammatory elbow disease is characterized by osteoporosis and surrounding soft tissue disorders.

Aims

To evaluate the clinical efficacy of total elbow arthroplasty, and to discuss the surgical skills and complication management of patients who received surgery through the retrospective analysis of the clinical and follow-up data.

Methods

13 patients with advanced inflammatory elbow disease treated with semi-restricted CM prosthesis in the Department of Orthopedics of Affiliated Hospital of Nanjing University of Chinese Medicine from January 2014 to June 2020. Through the retrospective analysis of the clinical and follow-up data, the clinical efficacy was evaluated, and the surgical skills and complication management of these patients were discussed.

Results

All patients were followed up for 13–89 months, with an average of (53.15 ± 24.20) months. The MEPS and HSS scores at each follow-up point after operation and at the last follow-up were satisfactory. There were 3 cases of periprosthetic fractures during the operation, 1 case of delayed incision healing, 1 case of ulnar nerve palsy, and 1 case of pain around the elbow joint after operation.

Conclusion

Elbow arthroplasty can effectively relieve joint pain, correct joint deformity, improve joint stability, and restore elbow joint function for patients with advanced inflammatory disease of the elbow joint.

elbow arthroplasty

advanced inflammatory elbow disease

rheumatoid arthritis

pigmented villonodular synovitis

clinical efficacy

management of complications

Arthroscopic surgery is currently the first choice for surgical treatment of inflammatory elbow disease with severe symptoms^2,22.However, for patients with advanced elbow articular fusion and loss of function, elbow fusion and total elbow arthroplasty(TEA) are alternative^13,16,28. Arthrodesis can only retain some of the necessary daily functions, and is generally only used for older patients with low functional requirements. TEA has a wider range of applications. Common inflammatory joint diseases that lead to loss of elbow function include rheumatoid arthritis(RA), pigmented villonodular synovitis(PVNS), and infectious arthritis(IA)^16,18,25,28. Patients with this disease often have poorer soft tissue conditions, a greater risk of osteoporosis, and looser joint capsule and ligament-stabilizing structures than degenerative elbow disease^5,9,17. Therefore, surgeons may face some more difficult situations when performing TEA in these patients. From January 2014 to June 2020, the joint center of our hospital completed 13 cases of elbow arthroplasty in patients with advanced inflammatory elbow disease. We recorded and reviewed the complete follow-up data, which are reported as follows.

1.1 Inclusion and exclusion criteria Cases were selected according to the following criteria: ①TEA was performed due to inflammatory elbow joint disease; ②Inflammatory joint disease did not involve other large joint functions of the upper limbs, such as shoulder and wrist joints; ③Expressed their subjective feelings well, and cooperated with objective physical examination. Patients who were lost to follow-up or with incomplete follow-up data, or who were clearly documented noncooperation with perioperative management were excluded.

1.2 Data 13 patients were included in the study, including 12 unilateral (7 left elbow, 5 right elbow) and 1 bilateral; 3 males and 10 females, aged 46–74 years, with an average age of (56.07 ± 6.89) years; 11 cases were RA, the course of disease was 2–20 years, with an average of (10.42 ± 7.56) years; 2 cases were PVNS, the course of disease was 2 years and 4 years, respectively. The underlying diseases of the patients included hypertension in 4 cases, cerebral infarction in 1 case, type II diabetes in 1 case, and thrombocytopenic purpura in 1 case. All patients had osteoporosis in preoperative bone mineral density examination.

1.3 Operation Take the supine position after general anesthesia, sterilize after tourniquet is installed. Centered on the lateral side of the medial epicondyle of the ulna, a longitudinal incision of about 15 cm in length was made close to the inside of the tip of the olecranon, and the ulnar nerve was freed to the first motor branch and protected. Strip the triceps from the inner and outer sides, keep the olecranon attachment point of the triceps, valgus the triceps, and expose the elbow joint. The tip of the ulna was excised, the collateral ligaments on both sides were incised, the elbow joint was dislocated by extreme pronation and supination of the forearm, and the proliferating inflammatory synovium was excised. Prepare the humerus, saw off the middle of the pulley, open the medullary cavity with a high-speed drill, drill out the tunnel, select an appropriate osteotomy guide for osteotomy, install the humerus prosthesis after reaming the medullary cavity, strip the anterior joint capsule, and remove the humeral pulley. The front edge of the cortical bone is polished rough. Then operate the ulna part, open at the base of the coracoid process and ream the pulp, install the ulnar prosthesis and then reset the elbow joint, evaluate the size of the prosthesis and the range of motion of the elbow joint, remove the trial mold after being satisfied, rinse the medullary cavity, and use the prosthesis stem according to the bone cement was injected into the length, and the prostheses on the ulna and humerus were installed respectively. All prostheses used in the operation were Coonrad-Morrey prostheses (Zimmer, USA). A bone block with a thickness of 3–4 mm, a length of 20mm and a width of 15mm was implanted between the anterior cortical bone of the humerus and the prosthesis wing. Check the range of motion of the elbow joint, preposition the ulnar nerve, release the tourniquet and electro-coagulate to stop the bleeding. At last, place a drainage tube and then close the incision and wrap it under pressure.

1.4 Post-operative and follow-up Elastic bandage was applied for compression dressing, and the affected limb was suspended in a position of 50° abduction and 80° flexion. Early postoperative fistula exercises to promote venous return. When the drainage volume was less than 30ml/d, the drainage device was removed, the compression bandage was released, and a neck-wrist sling was used, and patients were encouraged to perform active elbow flexion and extension exercises. Within 3 months after the operation, the weight of the affected limb should be less than 1kg, and it is forbidden to lift more than 5kg for life^1,14. Anti-inflammatory, analgesic, detumescence and anti-osteoporosis treatments were started on the second postoperative day. Long-term follow-up of patients after discharge, mainly outpatient follow-up, supplemented by telephone, home visits and other follow-up methods.

1.5 Evaluation indicators The operation time, intraoperative blood loss, and postoperative complications were recorded; the MEPS and HSS elbow joint scores were evaluated before operation, 3 months after operation, 1 year after operation, and at the last follow-up. The range of motion (flexion, extension, and rotation) of the elbow joint was followed up to evaluate the function of the elbow joint. The frontal and lateral X-rays of the affected elbow were reviewed at each follow-up, and the stability of the prosthesis was evaluated by the range of the translucent area combined with the elbow joint function score (Fig. 1).

1.6 Statistical methods SPSS 26.0 (IBM, USA) statistical software was used for statistical analysis, measurement data were expressed as (‾x ± s ), and the comparison of MEPS, HSS elbow score, flexion-extension and rotation range at each follow-up time point was performed by rank sum test, P < 0.05 was considered statistically significant difference.

2.1 Patient Follow-up Information List (Table 1)

2.2 Management of Complications One patient with RA with severe osteoporosis suffered fractures of the left lateral condyle of the humerus and the medial and lateral condyle of the right humerus during the operation, which were fixed with titanium needles and tension bands, and an elbow brace with adjustable range of motion was worn for 1 month after the operation. The follow-up 10 months later showed that the fractures on both sides were osseous healing, the joint prosthesis was stable, and the elbow joint function was satisfying (Fig. 2); 1 case of ulna fracture occurred during the operation and was binding with wire and healed after 6 months with satisfied function(Fig. 3). The incision was difficult to heal in one case, and it was healed by dressing change 3 weeks after the operation; 1 case of ulnar nerve palsy occurred, and after taking antitumor and nerve nutrition drugs combined with acupuncture for 3 months, the ulnar nerve palsy disappeared, and no sensory and motor dysfunction remained. During the follow-up period, one patient had persistent pain around the elbow joint for 1 month after the operation, and was treated with celecoxib combined with pregabalin and performed rehabilitation exercises, the pain was relieved after 3 months of treatment

Table 1

Data of Follow-up Information
Case	Gender	Age(ys)	Side	Indication	Date	Follow-up (months)	Complications
1	Female	69	Left	RA	2014.02	89	Fracture of ulna
2	Male	50	Left	RA	2014.12	79	None
3	Female	53	Right	RA	2015.04	75	None
4	Female	46	Right	RA	2015.04	74	Delayed healing
5	Female	74	Right	RA	2015.10	69	None
6	Male	51	Right	PVNS	2016.05	62	None
7	Female	50	Left	RA	2017.02	53	None
8	Female	62	Right	RA	2017.08	47	None
9	Female	57	Left	RA	2018.01	42	Ulnar nerve neurapraxia
10	Female	59	Left	RA	2018.05	38	None
11	Male	52	Left	RA	2018.07	36	Elbow pain
12	Female	55	Left	PVNS	2020.04	14	None
13	Female	58	Bilateral	RA	2020.05	13	Fracture of the lateral condyle of the left humerus and fractures of the medial and lateral condyles of the right humerus

2.3 MEPS The MEPS preoperative, 3 months postoperative, 1 year postoperative, and the last follow-up were (30.21 ± 8.62), (83.71 ± 3.91), (88.64 ± 2.62), and (89.29 ± 2.4), respectively. Pain, stability, daily life and motor function were significantly improved at any follow-up compared with preoperative, and the difference was statistically significant (P < 0.05)(Table 2 and Fig. 4).

Table 2

Comparison of MEPS between preoperative and postoperative follow-up
Follow-up	Pain	Mobility	Stability	Function	MEPS
Preoperative	14.64 ± 6.34	3.64 ± 1.82	5.86 ± 1.35	6.07 ± 5.94	30.21 ± 8.62
3 months post-op	36.57 ± 2.71^#	17.36 ± 1.82^#	9.43 ± 0.94^#	20.36 ± 3.08^#	83.71 ± 3.91^#
1 year post-op	40.07 ± 1.14^#△	17.79 ± 1.48^#	9.36 ± 0.93^#	21.43 ± 2.34^#△	88.64 ± 2.62^#△
Last follow-up	40.50 ± 1.51^#△	17.86 ± 1.46^#	9.43 ± 0.85^#	21.50 ± 2.21^#△	89.29 ± 2.40^#△
Notes: #Compared with preoperative, the difference was statistically significant (P < 0.05); △Compared with 3 months postoperative, the difference was statistically significant (P < 0.05)

2.4 HSS The HSS of elbow joint preoperative, 3 months postoperative, 1 year postoperative, and the last follow-up were (25.29 ± 1.73), (72.00 ± 2.63), (87.57 ± 3.41), (88.36 ± 3.00), respectively. In terms of pain, upper limb function, muscle strength, sagittal range of motion and range of motion of flexion, extension and rotation, there were statistically significant differences between postoperative and preoperative (P < 0.05) (Table 3 and Fig. 5).

Table 3

Comparison of HSS between preoperative and postoperative follow-up
Follow-up	Pain	Function	Muscle strength	Arc of flexion-extension	Flexion-extension-rotation mobility	HSS
Preoperative	5.36 ± 0.63	6.07 ± 1.14	2.36 ± 1.01	5.14 ± 1.56	6.57 ± 0.85	25.29 ± 1.73
3 months post-op	22.93 ± 1.59^#	13.86 ± 1.51^#	6.43 ± 1.02^#	13.93 ± 1.14^#	14.86 ± 0.95^#	72.00 ± 2.63^#
1 year post-op	26.43 ± 1.02^#△	18.21 ± 1.19^#△	8.79 ± 0.89^#△	16.57 ± 1.02^#△	17.57 ± 1.16^#△	87.57 ± 3.41^#△
Last follow-up	26.64 ± 1.28^#△	18.57 ± 1.09^#△	8.86 ± 0.95^#△	16.64 ± 0.93^#△	17.64 ± 1.34^#△	88.36 ± 3.00^#△
Notes: #Compared with preoperative, the difference was statistically significant (P < 0.05);△Compared with 3 months postoperative, the difference was statistically significant (P < 0.05)

Table 4: Comparison of ROM of elbow between preoperative and postoperative follow-up

Follow-up	Extension	Flexion	Arc of flexion-extension	Pronation	Supination	Arc of pronation- supination
	Extension	Flexion	Arc of flexion-extension	Pronation	Supination	Arc of pronation- supination
Preoperative	54.64±9.30	94.64±10.82	39.64±11.51	37.14±8.71	38.21±6.08	75.71±12.84
3 months post-op	30.36±5.71^#	128.93±8.81^#	100.36±6.34^#	70.36±7.20^#	67.86±6.71^#	138.57±9.89^#
1 year post-op	18.57±4.57^#^△	131.43±6.02^#	111.79±7.50^#^△	75.00±6.20^#^△	73.57±4.97^#^△	148.57±8.64^#^△
Last follow-up	18.57±4.57^#^△	131.07±5.94^#	112.14±7.52^#^△	75.36±6.03^#^△	73.93±4.01^#^△	149.29±8.96^#^△

Notes: #Compared with preoperative, the difference was statistically significant
(P<0.05); △Compared with 3 months postoperative, the difference was statistically significant (P<0.05)

2.5 ROM of elbow The flexion and extension ranges preoperative, 3 months postoperative, 1 year postoperative, and the last follow-up of the elbow were (39.64 ± 11.51)°, (100.36 ± 6.34)°, (111.79 ± 7.5)°, and (112.14 ± 7.52)°, respectively. The rotation ranges of the elbow were (75.71 ± 12.84)°, (138.57 ± 9.89)°, (148.57 ± 8.64)°, (149.29 ± 8.96)°, and the all range of motion of the elbow joint postoperative were significantly different from those preoperative (P < 0.05) (Table 4 and Fig. 6).

Surgical treatment of inflammatory elbow disease is challenging⁸. The activation of the inflammatory response and the long course of the disease often result in complicated elbow soft tissue conditions, ligament laxity and osteoporosis. For short-term inflammatory elbow disease, physicians generally choose to try arthroscopic synovectomy, open or arthroscopic arthrolysis^8,22. However, these surgical methods are difficult to accurately restore the function of the elbow joint for patients with advanced articular surface stenosis^1,10,22. For patients with inflammatory elbow disease resulting in less than 30° of elbow extension and only 120° of flexion, we consider TEA if the articular surface is very narrow. However, the reality is that many patients with inflammatory elbow joint disease do not choose TEA until the range of motion of the elbow joint is very poor because they are accustomed to multiple joint insufficiencies^12,23. The goal of TEA is to rebuild a painless, stable elbow joint that can perform daily life and work independently. This study investigated the clinical efficacy of TEA in the treatment of patients with advanced inflammatory elbow disease. Overall, the postoperative MEPS and HSS of the patients were significantly improved compared with those before the operation, and the flexion, extension and rotation functions were significantly improved. At 3 months after the operation, the patients had basically achieved obvious treatment benefits. There was no significant difference in MEPS and HSS at 1 year after surgery and at the last follow-up, indicating that the patient's treatment benefit had stabilized at 1 year after surgery.

For TEA in inflammatory elbow disease, intraoperative and postoperative complications are one of the main concerns of this study. We used the Coonrad-Morrey semi-restrictive artificial total elbow prosthesis in the patients included in this study, so part of our discussion of complications was specific to this joint prosthesis. The Coonrad-Morrey semi-restrictive artificial total elbow prosthesis is theoretically designed to have a range of flexion and extension from 0° to 160°, as well as 8° of pronation and supination²⁶. This semi-restrictive design allows extensive soft-tissue release and partial resection of the medial and lateral collateral ligaments of the elbow joint with a small amount of osteotomy^19,20,24,26, which is currently routinely used in our center. For patients with inflammatory elbow joint disease, we are very concerned about the intraoperative fractures. The increase in the amount of osteotomy and the opening of front of the trochlear can easily lead to intercondylar fractures of the humerus. We routinely performed CT to determine the extent of bone defect before surgery, so as to determine the amount of osteotomy during surgery. During the operation, we reamed the marrow according to the anatomy of the marrow cavity, and used a high-speed drill to open the opening with gentle movements. The trochlear bone in the middle of the humeral condyle is very thin and has an inclined angle, so it is very prone to fracture in patients with osteoporosis. The fracture line generally extends from the opening of the enlarged bone marrow to the humeral condyle. This fracture can cause instability of the elbow joint, so we all performed one-stage immobilization during the operation. There were 2 patients with humeral condyle fracture and ulna fracture, and even one case was bilateral fracture after bilateral surgery in our study. Fortunately, with tension band fixation and postoperative anti-osteoporosis treatment, the patient's fracture healed completely, the prosthesis was stable, and the elbow joint function was good at follow-up.

In addition, in the study, there were some other complications. One patient experienced delayed healing of the incision, postoperative swelling around the incision, and exudation of serum-like fluid, and the patient's incision healed after 3 weeks of continuous dressing changes. In this patient, the intra-articular synovial hyperplasia was severe. We thought that the continuous exudation and delayed healing of the surgical incision may be related to the severe synovial lesions in the patient's elbow joint. It may be necessary to clean the inflamed synovium as much as possible during TEA. Another patient developed pain around the elbow joint with no clear localization, resulting in limited movement in the early postoperative period. After 3 months of drug treatment, the pain was significantly improved, and no pain occurred after that. This patient was the patient with the lowest satisfaction with the procedure early in the study. This middle-aged male RA patient had been taking steroid hormones and meloxicam for a long time due to the underlying disease. The patient went to the outpatient clinic after one month of postoperative pain. The patient's pain gradually alleviated after the use of pregabalin. We thought that this may be related to the sensory nerve damage in part of the articular capsular branch.

In this study, all patients had the ulnar nerve prepositioned. One patient developed ulnar nerve palsy, which was manifested as a positive paper clip test. The dermatome below the elbow of the ulnar nerve was hypoesthesia, and the symptoms disappeared after 3 months of conservative treatment. According to literature reports, the incidence of ulnar nerve injury in TEA is about 3%^4,10,15. It is related to the surgical approach^6,11,21, the use of tourniquets, intraoperative traction, thermal injury of bone cement, hematoma compression, and swelling of the limbs. Most of them are temporary and usually recover within a few days to 1 year after the operation. If there is a motor dysfunction in the ulnar nerve innervation area, or if the sensory loss is not relieved and becomes progressively worse, surgical exploration and repair should be performed in time^7,10,28. Controversy still exists as to whether the ulnar nerve is prepositioned during surgery. We believe that it is not critical whether the ulnar nerve is prepositioned or not. What is important is to pay attention to the protection of the ulnar nerve throughout the operation¹⁰. Before surgery, the operator should pay attention to whether the patient has undergone surgery involving the ulnar nerve in the past, and choose an appropriate surgical approach to avoid the irritation of the ulnar nerve caused by the postoperative scar. When injecting bone cement, be care to prevent the thermal damage to the ulnar nerve caused by the overflowing bone cement, and shorten the use time of the tourniquet. After the operation, the tourniquet was loosened and the bleeding was fully stopped before suture. Drainage was placed to reduce the direct compression of the ulnar nerve by the hematoma. In addition, take anti-swelling drugs after surgery and pay attention to whether the bandage is too tight, so as to avoid excessive swelling of the limbs and damage to the ulnar nerve. Prepositioning of the ulnar nerve can avoid direct contact between the ulnar nerve and the prosthesis, and reduce the incidence of ulnar nerve symptoms during activity^3,27. Especially for patients with inflammatory elbow joint disease, inflammation and scarring are more likely to occur in the joint. Preposition of the ulnar nerve may be safer, and the prepositioned ulnar nerve is less stimulated in the event of osteolysis and loosening of the prosthesis^1,10,23.

There are some obvious shortcomings in this study. Due to the low prevalence of TEA and the epidemiological characteristics of the primary disease, there were few studies that met the inclusion criteria. And the diseases included in this study are only RA and PVNS, which cannot objectively and comprehensively reflect the clinical efficacy of TEA in the treatment of patients with advanced inflammatory elbow disease.

TEA in the treatment of advanced inflammatory elbow disease can significantly improve the elbow function of patients. Potential complications of TEA in the treatment of advanced inflammatory elbow disease include fractures, delayed incision healing, pain, and ulnar nerve palsy, which should be properly managed to obtain satisfactory clinical outcomes.

Ethical statement

This study is a retrospective study which following the Declaration of Helsinki. It’s approved by the Ethics Committee of the Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, and the approval number is 2022NL-120-01.

Funding

This work was supported by the National Natural Science Foundation of China(81804117)

Conflicts of interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Ethics approval

This study was approved by the Ethics Committee of the Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, and the approval number is 2022NL-120-01.

Consent to participate

Not applicable

Consent for publication

The publication has been approved by all co-authors.

Availability of data and material

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Code availability

Not applicable

Authors' contributions

Xin Liu was responsible for data analysis and article writing. Hao Chen contributed to data collection and language editing. Peng Xue, Hongzhong Xi and Guangquan Sun contributed to the data collection. Bin Du was responsible for the study design and correspondence. All authors read and approved the final article.

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Elbow arthroplasty for advanced inflammatory elbow disease—rheumatoid arthritis and pigmented villonodular synovitis

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