Complication and Revision Rates Following Total Elbow Arthroplasty

doi:10.1016/j.jhsa.2010.09.036

The Journal of Hand Surgery

Volume 36, Issue 1, January 2011, Pages 68-73

https://doi.org/10.1016/j.jhsa.2010.09.036 Get rights and content

Purpose

To determine the complication rates after total elbow arthroplasty (TEA) in a large and diverse patient population.

Methods

We identified patients undergoing TEA as inpatients in the years 1995 to 2005 using California's Discharge Database. Short-term outcomes of interest included rates of infection or wound complications, revision, reoperation, and pulmonary embolism that were diagnosed during an inpatient hospital admission and mortality within 90 days of index surgery. Longer-term outcomes analyzed included rates of revision, amputation, and conversion to fusion. We used regression models to estimate the role of patient and provider characteristics in predicting the rates of adverse outcomes.

Results

We identified 1,625 patients undergoing TEA. Early complications, defined as those requiring inpatient re-admission within the first 90 days after index surgery, were identified in 170 patients, and 132 patients required reoperation. Eighty one patients required revision in 90 days, and 48 underwent revision within one year. Early infections and wound complications requiring readmission occurred in 88 patients. In the 90 days after surgery, 4 patients had a pulmonary embolism and 10 patients died. One-hundred and twenty-one patients required revision, amputation, or fusion during the observation period, with a mean follow-up of 4 years. Hospital volume was not associated with increased risk of adverse outcomes.

Conclusions

We analyzed a large and diverse patient population undergoing TEA. The overall rate of short-term complications requiring inpatient treatment was high, at over 10% (170 patients), with almost 8% (132 patients) requiring reoperation within the first 90 days. Although population-based studies have shortcomings, they can add to the body of knowledge of less frequent procedures such as TEA.

Type of study/level of evidence

Therapeutic IV.

Section snippets

Data source

We obtained data for all hospital discharges in California in the years 1995 to 2005 from California's Office of Statewide Health Planning and Development through the patient discharge database. This database is compiled annually by the Office of Statewide Health Planning and Development and includes discharge abstracts from all nonfederal hospitals in California. Each discharge abstract includes codes for up to 20 inpatient procedures and 24 diagnoses per hospitalization. All procedures and

Patient sample

We identified a total of 1,625 patients undergoing inpatient TEA during the 11-year study period. Table 1 shows the incidence of TEA during this time period. The average length of follow-up was 4 years, and 121 patients had failure of the prosthesis during this time, which was defined as revision or removal of the implant, arthrodesis, or amputation during an inpatient admission. There were 581 males and 1,044 females. Median age was 56 years. A total of 364 patients had a diagnosis of

Discussion

Numerous studies have investigated the success of the various elbow prostheses. One difficulty in interpreting these studies is that each defines success and failure differently, and outcomes are reported at varying time intervals. In addition, most are performed at high-volume centers, often by the implant designer, and this may result in bias. It is therefore difficult to compare one implant with another, as well as determine the overall rates of complications. One of the goals of the current

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Cited by (61)

The Risk of Early Postoperative Complications Associated With Preoperative Immunosuppression in Patients Undergoing Total Elbow Arthroplasty
2023, Journal of Hand Surgery
Patients considering total elbow arthroplasty (TEA) may be receiving immunosuppressive therapy; however, the relationship between immunosuppressive medications and postoperative complications is not well defined. Our purpose was to assess the relationship between preoperative immunosuppression and short-term complications following TEA.
The American College of Surgeons National Surgical Quality Improvement Program database was reviewed from 2005 to 2020 to identify patients undergoing TEA. Procedures indicated for malignancy or infection were excluded. Patients were grouped according to preoperative chronic immunosuppressive status. Demographic and operative characteristics were compared between groups. The 30-day incidence of complications and reoperations were compared between groups. Multiple logistic regression models, inverse-weighted by propensity scores, were used to calculate odds ratio (OR) of experiencing any complication or return to the operating room based on immunosuppression status and other demographic characteristics.
A total of 769 patients undergoing TEA were included, of whom 142 (18.5%) received chronic immunosuppression. Distribution of age, sex, race, body mass index, diabetes, and American Society of Anesthesiologists classification differed significantly between groups. Most procedures were performed on an inpatient basis, and the median operative duration was 148 minutes. Most procedures were indicated for fracture in the nonimmunosuppressed group and rheumatoid arthritis in the immunosuppressed group. Overall complication rates were 7.0% for immunosuppressed patients and 10.2% for nonimmunosuppressed patients. The incidence of complications and reoperations did not significantly differ between groups. After controlling for confounding and adjusting for patient characteristics, immunosuppressed patients were 0.52 times less likely to experience a complication. Additionally, there was no association between immunosuppression status and odds of return to the operating room.
Similar rates of complications were observed following TEA, regardless of preoperative immunosuppression status. Chronic immunosuppression does not appear to increase the rates of postoperative complications for patients undergoing TEA.
Prognostic II.
Comparison study of patient demographics and risk factors for infections following primary total elbow arthroplasty
2022, Seminars in Arthroplasty JSES
Infections are a feared complication following primary total elbow arthroplasty (TEA). Studies comparing baseline demographic profiles and identifying risk factors associated with developing surgical site infections (SSIs) or peri-prosthetic joint infections (PJIs), following primary TEA are limited. This study was therefore aimed to: (1) compare patient demographics; and (2) identify patient-related risk factors for the development of infections following a primary TEA.
Patients who underwent primary TEA from January 1, 2005 to March 31, 2014 were identified in an administrative claims database. The study group consisted of all patients who developed either SSIs within 90-days or PJIs within 2-years following the index procedure, respectively. A total of 23,134 primary TEAs were identified between 2005 and 2014, of which 757 (3.3%) were coded as being infected. Primary outcomes that were assessed included comparing baseline patient demographics and identifying patient-related risk factors for developing PJIs. Pearson's chi-square analyses were used to compare study group demographics to their counterparts. Welch's t-test was used to compare mean Elixhauser-Comorbidity Index scores between the cohorts. Multivariate binomial logistics regression was used to calculate odds-ratios (OR) for patient-related risk factors. A P value less than .05 was considered statistically significant.
Patients who developed infections were significantly different compared to their counterparts with respect to the variables analyzed. Patients developing infections were found to have a higher prevalence of comorbidities as measured by mean Elixhauser-Comorbidity Index scores in patients who developed SSIs (7 vs. 5, P < .0001) or PJIs (7 vs. 5, P < .0001) compared to their respective counterparts. The greatest risk factors for SSIs within 90-days following primary TEA were rheumatoid arthritis (OR: 1.80, P < .0001), being male (OR: 1.53, P = .009), and depressive disorders (OR: 1.52, P = .004), whereas iron deficiency anemia (OR: 2.04, P < .0001), rheumatoid arthritis (OR: 1.78, P < .0001), and pathologic weight loss (OR: 1.73, P < .0001) were associated with an increased odd of PJIs.
This study demonstrated statistically significant differences between patients who developed and did not develop infections following primary TEA and identified a myriad of risk factors associated with these adverse events. The results from this study can help identify high risk patients by orthopedic surgeon in order to potentially mitigate the incidence of either SSIs or PJIs in patients undergoing TEA.
Level III; Database Study, Retrospective Case-Control Prognosis Study
Assessing the hospital volume–outcome relationship in total elbow arthroplasty
2022, Journal of Shoulder and Elbow Surgery
Total elbow arthroplasty (TEA) is an effective intervention for multiple elbow disorders including complex fracture in elderly patients, post-traumatic arthropathy, inflammatory arthropathy, and distal humeral nonunion. Given its known therapeutic value and low utilization rate, an investigation into the thresholds for TEA institutional volume–outcome relationships is warranted. The purpose of this study was to identify TEA volume thresholds that serve as predictors of institutional outcomes including complications, readmissions, revisions, cost of care, length of stay (LOS), and non-home discharge. We hypothesized that increased institutional volume would be associated with decreased 90-day adverse outcomes and resource utilization.
The Nationwide Readmission Database was queried from 2010 to 2017 to identify all cases of TEA. Hospital volume was calculated using a unique hospital identifier and divided into quartiles. Outcomes such as complications, readmissions, revisions, cost of care, LOS, and non-home discharge were then analyzed by quartile. The same outcomes were assessed via stratum-specific likelihood ratio (SSLR) analysis to define volume strata among institutions.
SSLR analysis defined statistically significant hospital volume categories for each 90-day outcome. The volume category with the lowest complication rate was ≥21 TEAs per year (5.6%). The volume categories with the lowest readmission rates were 1-3 TEAs per year (4.7%) and ≥18 TEAs per year (9.2%). Revision rates were lowest in the volume categories of 1-5 TEAs per year (0.1%) and ≥18 TEAs per year (0.1%). Hospitals with ≥21 TEAs per year had the lowest cost of care and the highest rate of extended LOS (>2 days). SSLR analysis showed that non-home discharges decreased in a stepwise manner as volume increased. The lowest non-home discharge rate was associated with the volume category of ≥22 TEAs per year (20.3%).
This study defines TEA volume strata for institutional outcomes. The highest TEA volume strata were associated with the lowest rates of 90-day complications, revisions, and non-home discharges and the lowest cost of care. This trend is likely attributable to the benefits of high-volume institutional experience and standardized patient-care processes.
The Impact of Cement Mantle Characteristics on Early Loosening in Primary Total Elbow Arthroplasty
2022, Journal of Hand Surgery
To assess the association between cement mantle characteristics and early radiographic loosening in total elbow arthroplasty (TEA). We aimed to determine whether shorter mantle heights (<20 mm) were associated with loosening.
We reviewed primary TEAs from a single healthcare system from 2006 to 2020. TEAs complicated by infection or performed for oncologic conditions were excluded. Initial postoperative radiographs were reviewed to determine cement mantle and component characteristics (mantle quality, mantle height, and component angulation). One-year postoperative radiographs were reviewed to assess for implant loosening, and we compared demographics and radiographic criteria for cases with and without early loosening. We noted whether cases underwent subsequent revision for aseptic osteolysis.
A total of 54 TEA cases were included. Forty percent of ulnar and 24% of humeral mantles were classified as short (between 1 and 19 mm). According to the Morrey classification, 6 (11%) cases had an inadequate cement mantle Twenty-four (45%) cases had radiographic evidence of loosening at 1 year. Of the cases with early loosening, 6 (25%) had initial inadequate mantle quality. There were no inadequate mantles in the group without loosening. There were no statistically significant differences in mantle heights for cases with and without loosening at 1 year after surgery. Eight (33%) cases underwent revision in the group with early loosening compared with 1 (3%) case without early loosening.
Inadequate cement mantle quality was associated with an increased risk of early aseptic loosening after primary TEA. Cement mantles that extended past the tip of the prosthesis were not associated with loosening. Considering the potential need for future revision and morbidity of cement removal, surgeons should focus on mantle quality and carefully plan mantle height because shorter heights may not be associated with early implant failure.
Prognostic II.
Total Elbow Arthroplasty: A Descriptive Analysis of 170 Patients From a United States Integrated Health Care System
2021, Journal of Hand Surgery
Citation Excerpt :
One in 4 patients who underwent TEA returned to ED within 90 days. Although the 30-day readmission rate was similar to that of other studies,23,25 the 90-day hospital readmission rate was higher than that previously reported.19,20 In comparison, the incidence rates of the 90-day ED visits and readmissions following primary shoulder arthroplasty in the same integrated health care system were 11.9% and 4.8%, respectively,32 although this sample comprised elective procedures.
Total elbow arthroplasty (TEA) can be used, with varying degrees of success, for the treatment of rheumatoid arthritis, osteoarthritis, and distal humerus fractures and their sequelae in elderly patients. Some of the largest studies of TEA have included data from more than 20 years ago and may not reflect the current practice of TEA. We sought to describe a modern cohort of patients who underwent TEA in a United States integrated health care system.
All patients aged 18 years and older who underwent primary unilateral TEA from January 1, 2009, through March 31, 2018, were identified to conduct a descriptive study. The patients’ characteristics and demographics, including age, body mass index, sex, diabetes status, American Society of Anesthesiologists classification, and surgical indication, were recorded. The crude cumulative revision probability as well as the 90-day postoperative incidence rate of emergency department visit, readmission, and mortality was calculated.
A total of 170 patients met our inclusion criteria. The annual procedure volume nearly doubled, from 11 procedures in 2009 to 21 procedures in 2017. The most common indication for TEA was fracture (40.6%), followed by rheumatoid arthritis (36.5%). At 4-year follow up, the crude cumulative revision probability was 9.8% (95% confidence interval, 5.6%–16.9%). Of the 170 patients who underwent TEA, 43 (25.3%) experienced a 90-day emergency department visit, 24 (14.1%) experienced a 90-day readmission, and 2 (1.2%) died within 90 days postoperatively.
This cohort of patients who underwent TEA using modern implants showed a notable increase in the volume of TEA over the study period, with more TEAs performed for trauma. The incidence of readmission and emergency department visits following TEA were high in this study. Further studies are needed to better define the current practice of TEA in the community at large.
Therapeutic IV
Differences in 30-day outcomes between inpatient and outpatient total elbow arthroplasty (TEA)
2020, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
This study reported a 90-day major complication rate of 7.1%, a reoperation rate of 3.5%, and a readmission rate of 3.5% in patients who had TEA in the ambulatory setting. They compared these rates with those published in inpatient studies and came to the conclusion that same-day discharge after TEA is a safe and viable option for a carefully selected group of patients when combined with attentive follow-up.22,27 In comparison to Stone et al, our study showed lower rates of complications (2.5% vs. 7.1%), reoperation (1.9% vs. 3.5%), and readmission (0.9% vs. 3.5%) after outpatient TEA.
As the health care system in the United States shifts toward value-based care, there has been increased interest in performing total joint arthroplasty in the outpatient setting to optimize costs, outcomes, and patient satisfaction. Several studies have demonstrated success in performing ambulatory total knee and hip arthroplasty. The purpose of this study was to compare short-term outcomes and complications after total elbow arthroplasty (TEA) across the inpatient and outpatient operative settings.
The American College of Surgeons National Quality Improvement Program database was queried to identify 575 patients undergoing primary TEA using the Current Procedural Terminology code 24363. Of this sample, 458 were inpatient and 117 were outpatient procedures. Propensity score matching using a 3:1 inpatient-to-outpatient ratio was performed to account for baseline differences in several variables—age, sex, body mass index class, American Society of Anesthesiologists class, and various comorbidities—between the inpatient and outpatient groups. After matching, the rates of various short-term outcomes and complications were compared between the inpatient and outpatient groups.
Inpatient TEA was associated with a higher rate of complications relative to outpatient TEA, including non-home discharge (14.9% vs. 7.5%, P = .05), unplanned hospital readmission (7.4% vs. 0.9%, P = .01), surgical complications (7.6% vs. 2.6%, P = .04), and medical complications (3.6% vs. 0.0%, P = .04).
Outpatient TEA has a lower short-term complication rate than inpatient TEA. Outpatient TEA should be considered for patients for whom such a discharge pathway is feasible. Future research should focus on risk stratification of patients and specific criteria for deciding when to pursue outpatient TEA.

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Scientific articleComplication and Revision Rates Following Total Elbow Arthroplasty

Purpose

Methods

Results

Conclusions

Type of study/level of evidence

Section snippets

Data source

Patient sample

Discussion

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Clin Epidemiol

J Chronic Dis

J Clin Epidemiol

J Shoulder Elbow Surg

Interposition arthroplasty with an Achilles tendon allograft as a salvage procedure for the elbow

J Bone Joint Surg

Total elbow arthroplasty with the Coonrad/Coonrad-Morrey prosthesisA 10- to 31-year survival analysis

J Bone Joint Surg

Infection after total elbow arthroplasty

J Bone Joint Surg

Total elbow arthroplasty in rheumatoid arthritis: a population-based study from the Finnish Arthroplasty Register

Acta Orthop

Factors predicting complication rates following total knee replacement

J Bone Joint Surg

Scientific article
Complication and Revision Rates Following Total Elbow Arthroplasty