Richard S. Bryan

Extensive posterior exposure of the elbow. A triceps-sparing approach.

Difficulty with triceps avulsion or loss of continuity after total elbow arthroplasty has prompted the development of a modified posterior approach to the elbow joint. The characteristic feature of this approach is that the triceps mechanism is reflected from medial to lateral in continuity with the forearm fascia and the olecranon and ulnar periosteum. A variant of the technique reflects the extensor mechanism from lateral to medial. The ulnar collateral ligament may be released from the humerus to provide more exposure, but the ligament must then be securely reattached. This approach, which provides extensive exposure to the elbow joint, has been employed in 49 consecutive total elbow arthroplasties and results show no loss of triceps function and no significant weakness. The approach has proved useful for treatment of intra-articular fractures of the distal end of the humerus and with synovectomy in the rheumatoid arthritic patient.

Total elbow arthroplasty. A five-year experience at the Mayo Clinic.

During the five years from 1973 through 1977, eighty Mayo and Coonrad total elbow arthroplasties were performed in seventy-two patients at the Mayo Clinic. Follow-up after at least two years (average, four years) revealed that the results were good in 60 per cent, fair in 16 per cent, and poor in 24 per cent. Pain was a major symptom in 80 per cent of the elbows preoperatively but in only 3 per cent postoperatively. At follow-up, motion had increased: extension-flexion by 10 degrees (average range, 29 to 131 degrees of flexion) and forearm rotation by 26 degrees (average range, 61 degrees of pronation to 59 degrees of supination). Excluding eleven prostheses with loosening for which revision was necessary, there were forty-four complications (55 per cent) after eighty procedures. Of these forty-four complications, eleven were ulnar neuropathies (two permanent and nine transient); four were wound-healing problems; ten, significant triceps weakness; eleven, intraoperative fractures of the medial or lateral supracondylar bone column; seven, deep infections; and one was an ulnar fracture. Although the complication rate was very high, most of the complications occurred during the early years of the study. Follow-up revealed twenty-nine elbows with radiolucency around the components: in twenty-five about the humeral and in four about the ulnar component. Revisions were performed in nineteen (24 per cent) of the eighty elbows: in eleven because of loosening, in seven because of deep infection, and in one because of ankylosis. Intraoperative supracondylar fracture and defective cementing of the prosthesis were important factors contributing to prosthetic loosening. When the arthroplasty was successful, the relief of pain was dramatic, stability was excellent, and the range of motion was superior to that provided by any other procedure currently available.

Total knee arthroplasty with the kinematic condylar prosthesis. A ten-year follow-up study.

Of 168 consecutive knees (118 patients) that had been treated with an arthroplasty with use of a kinematic total condylar prosthesis that allowed retention of the posterior cruciate ligament, 119 knees (eighty-four patients) were available for review at a mean of 10.0 +/- 0.7 years after the operation. The Hospital for Special Surgery knee score improved significantly, from a mean of 55 +/- 12 points preoperatively to a mean of 81 +/- 9 points at ten years (p < 0.0001). Radiolucent lines about the patellar component, present in thirty-five of eighty-three knees at the latest follow-up examination, were related to malpositioning of the tibial and femoral components. Six revisions were performed, and four of them were for a loose patellar component. The rate of deep infection was 1 per cent (one knee). Complications occurred in twenty-six knees (22 per cent). With revision as the end point, the rate of survival of the prostheses was estimated to be 96 per cent at ten years. The knee scores, the rate of survival of the implants, and the range of motion of the knees in the current study were similar to those reported previously for patients who had insertion of a total condylar prosthesis with sacrifice of the posterior cruciate ligament and for those who had substitution of the posterior cruciate ligament with a posterior stabilized prosthesis. A prosthesis that has a metal-backed tibial component and that allows preservation of the posterior cruciate ligament provides durable results, but loosening of the patellar component remains a major problem.

Complications and mortality associated with bilateral or unilateral total knee arthroplasty.

The incidence of complications, the need for secondary surgical procedures, and the mortality rate associated with bilateral replacement of the knee performed simultaneously, performed during the same hospitalization, or performed during separate hospitalizations were compared with those after unilateral replacement of the knee. The incidence of complications after 290 simultaneous bilateral procedures was 9.3 per cent, which compares favorably both with the incidence of 7.0 per cent after 228 bilateral procedures that were done during the same hospitalization and incidence of the 12.0 per cent after 234 bilateral procedures that were performed during separate hospitalizations. The incidence for each of these groups compares favorably with the incidence of complications of 11.0 per cent after 501 unilateral procedures. The incidence of reoperation was 2.4, 4.8, 8.5, and 5.6 per cent, respectively, in the four groups, and the incidence of mortality was 5.5, 0.9, 3.8, and 7.0 per cent. None of these differences were statistically significant. These data indicate that the incidence of morbidity and mortality that is associated with simultaneous bilateral total knee arthroplasty is no greater than when the procedure is performed during the same hospitalization or separate hospitalizations.

Review and analysis of silicone-rubber metacarpophalangeal implants

A series of 530 consecutive arthroplasties using silicone-rubber implants in 119 patients was reviewed. Clinical and roentgenographic evaluations were completed on sixty patients and 254 implants, with an average follow-up of two and a half years; the remaining fifty-nine patients were evaluated by questionnaire. All but three patients had rheumatoid disease, usually with severe deformity, and many of the patients underwent other procedures on the upper extremity; these procedures often precluded early motion after the arthroplasties. Three prostheses (0.6 per cent) were removed because of infection, and reoperation was required in 2.4 per cent of the joints. Detailed clinical follow-up of 254 prostheses revealed the following: for Swanson prosthesis-average motion 38 degrees, fracture rate 26.2 per cent, and recurrence of clinical deformity 11.3 per cent; for Neibauer prostheses-average motion 35 degrees, fracture rate 38.2 per cent, and recurrence of clinical deformity 44.1 per cent. It should be noted that use of early implant types and some variations from the designers recommended rehabilitation protocols were features of this series.

Long-term results of various treatment options for infected total knee arthroplasty.

Of 73 infected total knee arthroplasties treated from 1973 through 1984, the outcome of various management options revealed that solid arthrodesis was obtained in 70%. Fifteen percent of those with a solid fusion had residual pain or even recurrence of infection. Aggressive debridement was successful in eight of ten (80%). Long-term follow-up results show reimplantations were successful in eight of 15 (53%) but were functionally successful in only five of 15 (33%). A treatment plan based on functional considerations follows. For acute infections a very aggressive initial debridement followed by primary closure over an antibiotic-soaked pack is carried out. The prosthesis is left in place if at all possible and if the bone-cement interface has not demonstrated loosening. The knee is debrided every two or three days until negative cultures are obtained. Antibiotic beads are then inserted, with reexploration at three weeks with new cultures. Parenteral antibiotics are given for a three-week period initially. If two successive surgical debridements fail to reveal a positive culture, the knee is closed and rehabilitation is begun. For chronic infections, the recommendations of Wilde and Ruth are followed, employing antibiotic-impregnated beads and spacers with staged debridements similar to the method described above. Finally, an accurate definition of the true value of any of these options is predicated on long-term follow-up studies, since options that seemed promising as an initial procedure have proved disappointing as more experienced and longer follow-up study is obtained.

Arthrodesis of the knee following failed total knee arthroplasty.

In forty-five patients, who had an arthrodesis because of failed total knee arthroplasty, the cause was infection in forty, instability in two, failure of the prosthesis in two, and loosening in one. The arthrodesis succeeded in twenty-nine (81%) of thirty-six patients who had had a minimally or partially constrained arthroplasty and in five (56%) of nine who had had a hinge-type prosthesis inserted. The reasons for failure were severe bone loss, persistent sepsis, and loss of bone apposition after manipulation. The technique of arthrodesis did not seem to influence the final result. External fixation most commonly had to be used because of the infections and the device was kept in place for an average of ten weeks, after which immobilization in a cast was used until the arthrodesis healed.

Complications of total elbow arthroplasty.

The need for revision surgery for loosening exceeds 25% with tightly constrained prostheses but is much less with the semiconstrained designs. Resurfacing prostheses may be unstable if not adequately balanced by static and dynamic soft-tissue constraints. Infection is excessive (4%-9%), but resection arthroplasty is a reasonably good salvage procedure. Implant failure is rare. The ulnar nerve is subject to transient (10%) or, occasionally, partial dysfunction. Routine anterior translocation has been beneficial, but there is considerable variation in technique in this regard. Triceps insufficiency can be virtually eliminated with the Kocher lateral-to-medial or the Bryan lateral-to-medial triceps-sparing approach. Fractures of the ulna usually can be treated by cast application, but humeral fractures may require revision surgery because of component loosening. Some complications are decreasing in frequency, whereas others are becoming more widely appreciated. The procedure remains a challenging one, and is one that should be performed by those who are experienced in elbow surgery and who have a detailed knowledge of the numerous potential pitfalls.

Management of Infected Total Knee Arthroplasty

A retrospective study of the Mayo Clinic experience with the management of 61 infected total knee arthroplasties treated between 1970 and 1980 revealed rheumatoid arthritis as an underlying diagnosis in 47%. Previous operations had been performed in 58%. Arthrodesis was the most frequently utilized salvage technique and was successful in 83%. Reimplantation of a new prosthesis was successful in 63%. Debridement alone was successful in six knees when performed early for acute infections.

Revision total elbow arthroplasty.

Over a ten-year period, thirty-three consecutive revision total elbow arthroplasties were performed at our institution. These were assessed at a minimum of three years after the revision, with an average length of follow-up of sixty-one months. Eighteen (55 per cent) of the elbows had a good result and fifteen (45 per cent) had a poor result. The poor results were due to infection in three elbows, loosening of the prosthesis in six, inadequate motion in two, continued pain in two, and prosthetic failure in two. Additional surgical revision with another implant was done in the fifteen elbows that initially had a poor result. Eventually the result was good in twenty-four elbows. The three elbows that became infected after surgical revision had a resection arthroplasty and all were rated as having a fair result. The data from this study indicated that reimplantation is a viable option for the revision of a failed total elbow arthroplasty, although more than one revision may be required. They also suggested that young patients who have post-traumatic arthritis should not undergo a total joint replacement, and that revision procedures should be performed in settings that can offer several surgical options and by surgeons who have had experience with these options. Alternatives to reimplantation as a revision procedure should be considered in selected patients.