Eleven percent complication rate seen 3 months after total elbow arthroplasty

Database study also revealed 1% revision rate 90 days postoperatively and 3% revision rate after 1 year.

Issue: May 2010

A database population study evaluating patients who underwent total elbow arthroplasty revealed an 11% complication rate in the first 90 days postoperatively.

Lucie Krenek, MD, and colleagues at the University of California-Los Angeles, conducted the study based on data from the California Discharge Database, which includes information on all patients discharged from a California hospital.

“Because total elbow arthroplasty (TEA) is a relatively uncommon procedure, it is difficult to gather a large patient population, and this makes it well suited for database analysis,” Krenek, currently a resident at the David Geffen School of Medicine at UCLA, said at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons in New Orleans. “In addition, most reports come from high-volume institutions where the results may be biased toward better outcomes, and the patients at these institutions may differ from the general population.”

Common study group

The researchers included data from 1,625 patients who underwent TEA from 1995 to 2005. They excluded patients who underwent previous upper extremity arthroplasty, those with previous or concurrent infection and those with pathologic fracture.

Krenek said their results were similar to other studies: The majority of patients undergoing TEA (64%) were women, and most patients were older than 50.

Twenty-two percent of patients were identified as having rheumatoid arthritis, according to study author Nelson SooHoo, MD, also of UCLA. “The coding of diagnoses in an administrative database can be less accurate than the coding of procedures,” he told Orthopedics Today. “In this study … the remainder of patients [were] likely to have osteoarthritis.”

The revision rate within the first 90 days postoperatively was 1%, and within 1 year, it was 3%, Krenek said. Patients with osteoarthritis had a higher revision rate in the first 90 days than those with other diagnoses.

Prosthesis failure

Eight percent of patients had failure of the prosthesis, defined as requiring revision, amputation or fusion of the elbow. Early complications, or those occurring within 90 days postoperatively, included a 7.8% reoperation rate and a 5.4% readmission rate for wound infection and other complications. The researchers also found a 0.25% pulmonary embolism rate and a 0.6% mortality rate, which was higher in older patients, Krenek said.

“Except for a slightly increased rate of revision in patients with osteoarthritis, there were no differences between patients with osteoarthritis and rheumatoid arthritis,” she said.

She acknowledged several limitations of the study: The researchers were unable to determine which implants the patients used or the outcomes of each implant; only inpatients were included in the analysis, and so any complications treated on an outpatient basis were not evaluated; and functional outcomes were not evaluated.

“I think there are multiple complications that we don’t see,” Krenek said. “Also, we can’t follow these patients longitudinally, so we don’t know which patients underwent the specific complication.”

“The value of this study is that it allowed analysis of a large and diverse patient population undergoing TEA,” SooHoo said. “Although population-based studies have shortcomings, they can add to the body of knowledge of less frequent procedures such as TEA.” — by Tina DiMarcantonio

Reference:

SooHoo NF, Krenek L, Farng E, et al. Complication and revision rates following total elbow arthroplasty. Paper 056. Presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons. March 9-13, 2010. New Orleans.

Lucie Krenek, MD, and Nelson F. SooHoo, MD, the senior author of the study, can be reached at the University of California Los Angeles School of Medicine, 10945 Le Conte Ave., Room 33-55, Los Angeles, CA 90095; 310-267-5299; e-mail: Nsoohoo@mednet.ucla.edu.

Leesa M. Galatz, MD
Leesa M. Galatz

The authors should be commended on such an excellent study. The topic is relevant, timely, and unique. Total elbow arthroplasty lags behind that of other joints in reliability, predictability, and longevity. Previous literature documents the high complication rate and early failures, yet, most published series are limited by small numbers. Utilization of large databases, such as the California Discharge Database, and other registries represent the type of research needed to discern the outcomes of arthroplasty procedures in reality, not just in the hands of experts or large volume centers.

This research parallels the efforts of the American Academy of Orthopaedic Surgeons in establishing and incorporating the American Joint Replacement Registry (AJRR). While the current efforts focus on gathering level I data on hip and knee arthroplasty, this article highlights the importance of ultimately including upper extremity joints in the registry. The complication, reoperation, and revision rates cited by SooHoo and colleagues are, quite frankly, alarming, but unfortunately not surprising to surgeons with upper extremity practices. Large scale information gathering on all arthroplasty procedures represents an opportunity to vastly improve quality of patient care, and is imperative in the future where emphasis will be placed on quality, patient safety, and efficiency. Clearly, with regards to elbow arthroplasty, we have ample room for improvement.

– Leesa M. Galatz, MD
Shoulder and Elbow Service
Washington University Orthopedics
Barnes-Jewish Hospital
St. Louis, MO