The Total Elbow Arthroplasty Revision Rate Remains High Despite Technological Advances

Commentary Surgeons who utilize total elbow arthroplasty (TEA), particularly early in their career, are likely to develop a robust relationship with these patients because reoperations are common. The study by Hill et al. provides useful information regarding revision rates and complications following TEA. One of the strengths of the study is that it was performed at a single institution, using a single anatomic implant, with long-term follow-up. In contrast to traditional studies on TEA, the population in this study was treated predominantly for fractures and posttraumatic sequelae1. Because of a substantial increase in the use of disease-modifying antirheumatic drugs (DMARDs) and biologics, severe elbow rheumatoid arthritis has become increasingly rare2. However, severe distal humeral fractures and subsequent posttraumatic arthritis have become a more common indication for TEA2,3. Unfortunately, these conditions may occur more commonly in a younger population with higher demands compared with the typical patient with rheumatoid arthritis. This study had a high proportion of patients with posttraumatic arthritis, who have previously been shown to have a higher revision rate compared with the population with rheumatoid arthritis4,5. The importance of surgical technique and implant selection is emphasized in the study. A less-than-adequate cement mantle was associated with a higher incidence of aseptic humeral loosening, which has also been reported in the literature6. Short ulnar stems were associated with aseptic ulnar loosening. Prior authors have reported that a shorter humeral stem length led to earlier revisions with the Coonrad-Morrey implant, and a shorter stem was hypothesized to result in earlier loosening if the cement technique was less than adequate5. An additional important finding in the study was that those patients who underwent a reoperation for reasons other than infection had a greater risk of future surgery for infection. This highlights the importance of minimizing reoperations. Interestingly, there were no reoperations for excision of a native radial head, whereas reoperations were performed for failed prosthetic radial heads. The specific anatomic implant that was used provides the surgeon with the opportunity to link or unlink the humeral and ulnar components. This decision provides flexibility, and unlinking potentially leads to smaller forces transmitted to the cement junction; however, it also may lead to an additional procedure to link the components if instability occurs. This study provides practical data for orthopaedic surgeons to implement strategies to decrease the revision rate, including meticulous cementing technique, use of a longer ulnar stem, judicious use of unlinked components, and ultimately avoiding reoperations. Despite advances in implant design and technique, the revision rate remains high. As the shift away from low-demand patients with rheumatoid arthritis continues, further advances are needed to increase the ability to withstand the forces of a more active population and limit the revision rate.