Rates of Adverse Outcomes for Elbow Joint Replacement

Elbow joint replacement (called Total Elbow Arthroplasty or TEA) is possible but not a common procedure. Getting data on results of the TEA procedure can be difficult. In this study from California, surgeons used information from the California Discharge Database to get a picture of short- and long-term outcomes for patients of all ages, race/ethnicity, and diagnosis (e.g., rheumatoid arthritis, osteoarthritis, traumatic arthritis). Although both males and females were treated, there were twice as many females as males in the study.

Discharge records maintained over a period of 10 years (1995-2005) were analyzed. Problems were tallied for patients while still in the hospital (inpatient period) and for short-term (first 90-days) and long-term post-operative periods.

Type of measures used to gauge success versus failure of the total elbow arthroplasty (TEA) included rates of infection, delayed wound healing, and need for revision surgeries or reoperations. Deaths (usually from blood clots) in the first three months were reported at a rate of 0.62 per cent. Other serious complications such as amputation and conversion to joint fusion were also included.

The overall complication rate was fairly high at 10.5 per cent. Infections, wound complications, and blood clots headed the list of serious complications requiring hospital readmission. By nature of the thin soft tissues around the elbow, the rate of infection tends to be a problem no matter how careful the surgeon is. Most of these problems occurred early and meant the patient had to go back to the hospital for further care.

Surgeons are alarmed by these findings. They are especially concerned because this database doesn't include other complications that can be disabling such as nerve injuries, implant loosening, and fractures. On the positive side, 92 per cent of the implants did just fine and were still working well four years after being put in.

There were a few other issues that might have skewed results one way or the other. For example, patients from military hospitals or VA hospitals weren't included. Only patients treated in California were included, so the results may not be typical of other regions.

Even within the California system, the number of cases is probably under reported and surgeons don't always include the diagnosis, so it was impossible to compare results for the different types of elbow arthritis. That's unfortunate because it's possible that one group is at greater risk than another for complications just based on the type of problem (traumatic arthritis vs. rheumatoid arthritis vs. osteoarthritis).

Other studies have reported on the use of different types of implants available for the elbow. Although outcomes based on implant type weren't a focus of this study, the authors did report that comparisons haven't shown a difference in results based on implant design. In all cases, the database does not report patient satisfaction, which is a key outcome measure.

There's plenty of room for further studies to fill in and round out what we know about short- and long-term results of total elbow arthroplasty (TEA). The conclusion of this regional study (California only) was that complications are higher than expected or desired.

Patient results may be improved and costs decreased with further studies to find out why rates of failure, revision, and reoperation are so high (not to mention mortality or death rates). In this study, patient factors (age, sex, race/ethnicity) did not have an effect on death. A closer look at patient characteristics may also be helpful in reducing mortality and rates of other serious short- and long-term complications.

References: Lucie Krenek, MD, et al. Complication and Revision Rates Following Total Elbow Arthroplasty. In Journal of Hand Surgery. January 2011. Vol. 36A. No. 1. Pp. 68-73.