Results from a meta-analysis published in the Bone & Joint Journal support the efficacy of total elbow arthroplasty (TEA) for patients with rheumatoid arthritis (RA). Implant failure and complications were uncommon, though more frequent in younger patients, women, and unlinked prostheses.
While TEA is commonly performed in patients with end-stage arthritis, implant survival is often inferior to that observed in other major joints. Investigators sought to review TEA failure rate and identify risk factors for poor arthroplasty outcomes in patients with RA. The PubMed, MEDLINE, Cochrane Review, and Embase databases were searched from January 2003 through March 2019 for studies evaluating TEA in patients with RA. Two reviewers independently evaluated study eligibility and extracted data.
The primary outcome was implant failure. A meta-regression analysis was performed to identify correlates of implant failure. Secondary outcomes included complication rates, risk factors for complications, and clinical performance post-TEA. Clinical performance was assessed based on range of motion (ROM) measurements and the Mayo Elbow Performance Score (MEPS).
A total of 38 studies were included in the meta-analysis. The pooled cohort comprised 2118 patients with RA who underwent TEA. Mean follow-up time was 80.9 (range, 28.2-156.0) months; mean age was 61.0 (42.6-67.0) years. The majority (80.5%) of patients were women. The pooled implant failure rate was 16.1% (95% confidence interval [CI], 12.8-20.0%). In multivariate linear regression models, younger age (P =.034) and unlinked prosthesis design (P =.010) were associated with a higher risk for failure. The most common mode of failure was aseptic loosening, observed in 9.5% (95% CI, 7.1-12.4%) of TEAs. In regression models, women (P =.047) and patients with unlinked prostheses (P =.003) were more likely to experience aseptic loosening. The pooled rate of complications was 24.5% (95% CI, 20.3-29.3%). The most common perioperative complications were ulnar neuropathy (8.5%), wound healing problems (7.6%), deep infection (5.5%), fracture (5.2%), and triceps disruption (3.2%). Younger age was significantly correlated with complications in regression models (P <.001).
Overall, 24 studies reported clinical performance using ROM measurements. The pooled mean postoperative ROMs (95% CI) for flexion, extension, pronation and supination were 131.5° (124.2-138.8°), 29.3° (26.8-31.9°), 74.0° (67.8-80.2°), and 72.5° (69.5-75.5°), respectively. Eighteen studies reported postoperative MEPS; mean score was 89.3 (95% CI, 86.9-91.6) out of a possible 100, suggesting good to excellent elbow function.
Limitations of the study include that the level of evidence of the studies which were included were low (III or IV), and factors which may determine outcome such as RA disease activity, the baseline activity level of patients, or surgeons’ experience could not be analyzed.
Results from this meta-analysis support the continued use of TEAs for patients with end-stage RA. The risk-benefit profile may be less favorable among young patients and women. “These results can be of use when counselling patients about the expectations of TEA,” investigators wrote.
Chou T-FA, Ma HH, Wang J-H, et al. Total elbow arthroplasty in patients with rheumatoid arthritis: a systematic review and meta-analysis. Bone Joint J. 2020;102-B(8):967–980.