activities after total elbow arthroplasty
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J Shoulder Elbow Surg (2013) 22, 787-791
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Activities after total elbow arthroplasty
Jonathan D. Barlow, MD, Bernard F. Morrey, MD, Shawn W. O’Driscoll, MD, PhD,Scott P. Steinmann, MD, Joaquin Sanchez-Sotelo, MD*
Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
Background: Knowledge of patient activities after total elbow arthroplasty may help delineate the truefunctional gains obtained after replacement. Experience suggests that some patients may perform activitiesexcessively demanding on elbow implants, but compliance with activity restrictions recommended afterelbow arthroplasty is largely unknown.Materials and methods: All patients who underwent a primary or revision total elbow arthroplasty ata single institution from 2005 to 2007 were surveyed regarding their activity level. The University of Cal-ifornia, Los Angeles (UCLA) activity score and Mayo Elbow Performance Score were assessed. Patientswere also questioned about whether they recalled which activities were not recommended by their surgeon.Results: One hundred thirteen completed surveys were analyzed. There were 29 men and 84 women witha mean age of 65 years. Of the patients, 64 had primary and 49 had revision operations. The mean MayoElbow Performance Score was 77 points (range, 15-100 points). The mean University of California, LosAngeles activity score was 5 points (range, 1-10 points). Moderate-demand activities were performedby 94% of patients, and high-demand activities were performed by 40% of patients. Male gender anda diagnosis of fracture/nonunion was associated with increased performance of high-demand activities(P < .05). Eighty percent of patients remembered receiving postoperative restrictions, and of these patients,83% interpreted that they were compliant with their restrictions.Conclusion: Ninety-four percent of patients engaged in moderate-demand activities after total elbowarthroplasty. Forty percent engaged in high-demand activities. Factors correlated with more demandingactivities included male gender and diagnosis of fracture/nonunion. The vast majority of patients remem-bered receiving postoperative restrictions.Level of evidence: Level IV, Case Series, Treatment Study.� 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Total elbow arthroplasty; activities
4,9
Total elbow arthroplasty is an effective treatment formany patients with elbow dysfunction but remains plaguedby relatively high revision rates.4,9,10 Wear and asepticloosening are relatively common causes of failure, althoughthe rates of mechanical failure vary by implant design anddepartmental review board approval was obtained for this
04379).
uests: Joaquin Sanchez-Sotelo, MD, Mayo Clinic, 200
chester, MN 55905, USA.
ss: [email protected] (J. Sanchez-Sotelo).
ee front matter � 2013 Journal of Shoulder and Elbow Surgery
/10.1016/j.jse.2013.01.023
underlying diagnosis. In an attempt to decrease overallwear, most surgeons recommend activity restrictions. It isunclear whether providing these restrictions will decreasethe overall failure rate of these implants. Furthermore,patient compliance with provided restrictions is unknown.Although activity levels after hip, knee, and shoulderarthroplasty have been described, there is no information inthe English-language literature regarding patient-reportedactivities after total elbow arthroplasty.1,2,11 Knowledge ofpatient understanding of postoperative restrictions, as wellas their compliance, may help improve preoperative and
Board of Trustees.
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postoperative counseling of patients undergoing total elbowarthroplasty and help us understand the true relationshipbetween activity and mechanical failure.
The purpose of our study was to query a large number ofpatients who had undergone primary or revision total elbowarthroplasty to determine (1) their overall level of activityas measured by the University of California, Los Angeles(UCLA) activity score and the percentage of patientsparticipating in moderate- and high-demand activities; (2)patient factors associated with increasing postoperativeactivity levels, as assessed by correlating patient factorswith UCLA score and moderate- and high-demand activi-ties; and (3) patient understanding of and compliance withpostoperative restrictions, as measured by surveying pa-tients’ recall of restrictions and comparing this with theircurrent activity levels.
Materials and methods
All patients who underwent primary or revision total elbowarthroplasty at a single institution from 2005 to 2007 were iden-tified. There were 153 total elbow replacements identified.Surveys were sent by mail to all patients. To maximize the numberof patient responses, a follow-up survey was sent to nonre-sponders. Patients who did not respond to the second survey werecontacted by telephone. In total, 113 patients (74%) returned theirsurveys. A subset analysis comparing survey responders andnonresponders indicated that older patients were significantlymore likely to respond to their surveys than younger patients(P < .01). There was no correlation in survey response betweenpreoperative diagnosis, primary or revision operation, gender, orimplant type and.
Of those patients who returned a completed survey, 84 werewomen (74%) and 29 were men (26%). The mean age at the timeof the survey was 65 years (range, 23-87 years). The meanduration of follow-up after the index arthroplasty was 3.4 � 0.8years. Of the elbows, 57% had undergone primary and 43%revision arthroplasty. The underlying diagnosis was an acute distalhumeral fracture or nonunion in 56 elbows (50%), inflammatoryarthropathy in 40 (35%), and osteoarthritis, mostly post-traumatic,in 17 (15%). There were no statistically significant differencesin underlying diagnosis or primary versus revision proceduresbetween those who answered the survey and those who did not.The procedures were performed by 4 different surgeons.Two implants were used: the Zimmer Coonrad-Morrey elbowarthroplasty (Zimmer, Warsaw, IN) in 97 patients and theTornier Latitude elbow arthroplasty (Tornier, Edina, MN) in16 patients.
The survey was built to assess UCLA activity score andMayo Elbow Performance Score (MEPS) and to assess patientparticipation in 70 different activities of varying demand withthe operative arm (Appendix, available on the journal’s websiteat www.jshoulderelbow.org). Questions were derived from care-ful analysis of previously reported questionnaires evaluatingactivities after other joint arthroplasties. Examples of low-demand activities included cooking, driving, and pumping gas.Examples of moderate-demand activities included gardeningand hiking. Examples of high-demand activities includedsnow shoveling, chopping wood, and playing tennis. In addition,
patients were asked to note what activity restrictions they weregiven after their total elbow arthroplasty and whether theybelieved that they were compliant with the recommendations oftheir surgeon.
Patient-reported activities are summarized descriptively andare expressed as count (percentage) for categorical variables andmean with standard deviation for continuous variables, unlessotherwise stated. The effect of age, gender, underlying diagnosis,and type of surgery (primary vs revision) on these outcomemeasures was evaluated with c2 tests (for discrete variables)and 2-sample t tests or Wilcoxon rank sum tests (for continuousvariables). We examined the strength of the association betweenthe overall activity level (UCLA activity score) and the MEPS bycalculating Pearson or Spearman correlation coefficients.
Results
Elbow arthroplasty resulted in a mean MEPS of 77 � 19points (range, 15-100 points) at most recent follow-up. Themean UCLA activity score was 5 � 2 points (range, 1-10points). Ninety-four percent of patients performed at least1 moderate-demand activity. Forty percent of patients per-formed at least 1 high-demand activity. The most commonmoderate-demand activities were carrying groceries (81%of patients) and gardening (48% of patients). The mostcommon high-demand activities were shoveling snow (19%of patients), shoveling dirt (19% of patients), and placingluggage in an overhead compartment (19% of patients)(Table I).
There were several patient factors that were associatedwith higher activity levels. Men were more likely to engagein high-demand activities than women (59% vs 34%, P <.01). Men were also, however, more likely to only performlow-demand activities (10% vs 5%, P < .01) (Table II).When taken together, the mean UCLA activity score was5 points for men and 5 points for women (P ¼ .97). Themean MEPS in women was higher than that in men(80 points vs 68 points, P ¼ .003). Women had higherscores on the MEPS for the categories of pain (34 pointsvs 25 points, P ¼ .0035), motion (17 points vs 14 points,P ¼ .0035), and stability (9 points vs 7 points, P ¼ .0029).There was no significant difference between women andmen for the activities–of–daily living category (22 points vs24 points, P ¼ .22). There was a non–statistically signifi-cant trend toward decreased activity level with increasingage (P ¼ .16). The mean ages of patients completing high-,moderate-, and low-demand activities were 63 years,66 years, and 68 years, respectively. With the numbersavailable, primary or revision surgery was not associatedwith activity level (P ¼ .56) (Table III).
Operative diagnosis (post-traumatic arthritis/degenera-tive joint disease [DJD], inflammatory arthritis, or fractur-e/nonunion) was correlated with performance ofhigh-demand activities (P ¼ .02). Subgroup analysisshowed that this difference was due to increased perfor-mance of high-demand activities in patients undergoing
Table I Percentage of patients able to participate in surveyed activities
Low Moderate High
Activity No. of patients (%) Activity No. of patients (%) Activity No. of patients (%)
Cooking 102 (90) Carrying groceries 92 (81) Dirt shoveling 21 (19)Driving 94 (83) Gardening 54 (48) Snow shoveling 21 (19)Pumping gas 73 (65) Sexual intercourse 44 (39) Putting luggage overhead 21 (19)Treadmill 29 (26) Leaf raking 32 (28) Wheelbarrow use 10 (9)Stationary biking 26 (23) Dancing 31 (27) Free weights 10 (9)Horseshoes 2 (2) Lawn mowing 30 (27) Hunting/shooting 9 (8)Snowshoeing 0 (0) Swimming 27 (24) Sawing wood 8 (7)
Hiking 20 (18) Canoeing/kayaking 7 (6)Fishing 19 (17) Motorcycling 5 (4)Aerobics 16 (14) Road biking 5 (4)Motorboating 15 (13) Chopping wood 4 (4)Piano 12 (11) All-terrain vehicle 3 (3)Woodwork 8 (7) Baseball 3 (3)Jogging 8 (7) Mountain biking 3 (3)String instruments 7 (6) Basketball 3 (3)Diving 5 (4) Volleyball 2 (2)Bowling 3 (3) Racquetball/handball 2 (2)Metalwork 3 (3) Horseback riding 2 (2)Downhill skiing 2 (2) Football 2 (2)Pilates 2 (2) Archery 2 (2)Golf 1 (1) Doubles tennis 1 (1)Wind instrument 1 (1) Rowing 1 (1)Scuba diving 1 (1) Sailing 1 (1)Yoga 1 (1) Skydiving 0 (0)Percussion 1 (1) Waterskiing 0 (0)Cross-country skiing 1 (1) Soccer 0 (0)Brass instrument 0 (0) Ice hockey 0 (0)
Singles tennis 0 (0)Rock climbing 0 (0)Snowmobiling 0 (0)Tae kwon do 0 (0)Karate/judo 0 (0)Wrestling 0 (0)Boxing 0 (0)
Table II Highest-demand activity performed by patientsbased on gender
No. of patients (%)
Low Moderate High
Female 4 (5) 51 (62) 28 (34)Male 3 (10) 9 (31) 17 (59)
Significantly more men were able to complete high-demand activities
than women (P < .01). Significantly more men were only able to
complete low-demand activities (P < .01).
Table III Highest-demand activity performed by patientsbased on type of operation
No. of patients (%)
Low Moderate High
Revision 3 (6) 23 (48) 22 (46)Primary 4 (6) 37 (58) 23 (36)
There was no significant difference in activity level for patients
undergoing revision versus primary operation.
Activities after total elbow arthroplasty 789
total elbow arthroplasty for fracture/nonunion (53%) versusinflammatory arthritis (24%) (P ¼ .01). The percentage ofpatients with post-traumatic arthritis/DJD participating inhigh-demand activities was 37%, which was not signifi-cantly different from the fracture/nonunion group (P ¼ .3)or the inflammatory arthritis group (P ¼ .2) (Table IV).There was a significant confounding effect, however, of
gender on operative diagnosis, with an increasedpercentage of women in the inflammatory group (92%)compared with the fracture/nonunion group (60%) or thepost-traumatic arthritis/DJD group (79%) (P ¼ .002).A multivariate analysis indicated that the fracture/nonuniongroup was independently associated with increased activitylevel (P ¼ .005). There was no significant correlation
Table IV Highest-demand activity performed by patientsbased on operative diagnosis
No. of patients (%)
Low Moderate High
Post-traumatic arthritis/DJD 0 (0) 12 (63) 7 (37)Fracture/nonunion 2 (4) 24 (44) 29 (53)Inflammatory arthritis 5 (13) 24 (63) 9 (24)
Patients in the fracture/nonunion group were significantly more likely
to engage in high-demand activities than patients in the inflammatory
arthritis group (P ¼ .005). The post-traumatic arthritis/DJD group was
not significantly different from the other 2 groups.
790 J.D. Barlow et al.
between operative diagnosis and MEPS, UCLA score,or age.
Eighty percent of patients specifically rememberedreceiving postoperative restrictions after their total elbowarthroplasty. Ninety-seven percent of these patients accu-rately remembered postoperative restrictions. Of patientswho remembered restrictions, 83% believed they werecompliant with their restrictions. This indicates that justunder two-thirds of patients (64%) accurately rememberedand were compliant with their postoperative restrictions.
Discussion
In the literature, data regarding the specific activitiesperformed by patients after total elbow arthroplasty arelacking. Despite this, many surgeons advise specificactivity restrictions for patients after total elbow arth-roplasty. Knowledge of patient understanding of post-operative restrictions, as well as their compliance, may helpimprove preoperative and postoperative counseling ofpatients undergoing total elbow arthroplasty and help usunderstand the true relationship between activity andmechanical failure.
We assessed overall activity level using the UCLAactivity score. Though originally designed to assess activitylevel after hip arthroplasty, the UCLA activity score hasrecently been implemented in assessing general activitylevels in knee and shoulder arthroplasty patients.1,2,11 Inour study, the mean UCLA activity score was 5 � 2 points(range, 1-10 points). A UCLA score of 5 correlates to‘‘sometimes participates in moderate activity.’’
A large number of patients included in our study per-formed moderate- and high-level activities. Ninety-fourpercent of patients performed at least 1 moderate-demandactivity. Forty percent of patients performed at least 1high-demand activity. The mean age of patients in thissurvey was 65 years, which is in agreement with thedemographics of previous studies on elbow arthroplasty.6
Because of the elderly nature of this group, this mayskew some of the data toward lower-demand activitiesbecause of the overall functional capacity of the patients.
Despite this, a substantial number of patients engagedin activities that require both upper extremity fitness andoverall functional abilities, including shoveling dirt (19%),shoveling snow (19%), raising luggage overhead (19%),using a wheelbarrow (9%), and lifting free weights (9%).
Several patient-related factors were associated withincreasing activity levels. Men were more likely to engagein higher-demand activities (59% vs 34%, P < .01). Menwere also, however, more likely to engage in low-demandactivities (10% vs 5%, P < .01). This resulted in a meanUCLA score that was similar for men and women (5 pointsfor both). Notably, the MEPS was higher in women than inmen in this series (80 points vs 68 points, P ¼ .003).Previous studies regarding activities after total jointreplacement have also documented an increase in high-demand activities in men.2 The increase in high-demandactivities performed by men despite decreased MEPSvalues is an unexpected finding. Previous studies on activitylevels after shoulder arthroplasty have discussed a possible‘‘self-regulatory’’ function, in which patients decreaseactivity because of pain.11 In this series, this self-regulatorycorrelation seems to be better shown in women than in men.
Our series indicates that in a multivariate analysis,patients who have total elbow arthroplasty for fracture/nonunion are significantly more likely to engage in high-demand activities (53%) than patients with inflammatoryarthritis (24%). Patients with post-traumatic arthritis/DJD were between these 2 groups (37%) in terms ofactivities performed. Several studies have documented anincreased failure rate of total elbow prostheses in patientswith post-traumatic conditions.3,7,8 Interestingly, there wasno significant difference in MEPS values among patientsin the fracture/nonunion group, inflammatory group, andpost-traumatic group. This is in contrast to a previous studythat showed decreased MEPS values for patients withpost-traumatic conditions.6
Overall, just under two-thirds of patients accuratelyremembered and complied with postoperative restrictions.Although it is unclear whether these restrictions willprovide increased longevity of the implants, it is the prac-tice of 3 of our surgeons (B.F.M., J.S.-S., and S.P.S.) tocounsel all patients not to lift anything weighing over 10 lbor to repetitively lift more than 2 to 3 lb. The fourth surgeon(S.W.O.) recommends trying to make the arthroplasty lastas long as possible by limiting the total cumulative stresses(including magnitude and total cycles of load and limita-tions on the mechanical leverage on patients’ elbowimplants) without specific restrictions. No consensusrecommendations for postoperative activity level after totalelbow arthroplasty have been published, as have beenpublished for hip and knee arthroplasty.5
Our study has several limitations. First, the patient groupin this series was treated by several surgeons, with 2 elbowimplants used. As documented, the surgeons provideddifferent emphasis on postoperative restrictions. Using thislarge group of patients, however, allows a more detailed
Activities after total elbow arthroplasty 791
analysis. Second, there is some inherent selection bias inany survey-driven study. We attempted to mitigate this byhaving a series of patient contacts, and this resulted in a highresponse rate (74%). Third, there is no specific delineationregarding the frequency and duration of activities per-formed. Certainly this would have a significant effect on themechanical stresses on the implant. Finally, although thisstudy analyzed the activities of patients after total elbowarthroplasty, it does not directly correlate these activitieswith long-term survivorship or radiographic analysis.
Conclusions
The results of our study show that a substantialnumber of patients perform moderate- and high-demand activities after total elbow arthroplasty.Male gender and preoperative diagnosis of fracture/nonunion are associated with increased performanceof high-demand activities postoperatively. Two-thirdsof patients remember and comply with postoperativerestrictions after total elbow replacement. Somepatients do more than their surgeons would anticipate,raising concerns about the durability of elbowarthroplasty in patients performing higher-demandactivities. This study supports efforts to counsel pa-tients on the anticipated consequences of performingmoderate- and high-demand activities with totalelbow arthroplasties, as well as to develop elbowarthroplasty designs that are suitable for high-demandpatients.
Disclaimer
Shawn W. O’Driscoll reports that he has receivedroyalties from Tornier for work related to the subject ofthis article. All the other authors, their immediatefamilies, and any research foundations with which theyare affiliated have not received any financial payments
or other benefits from any commercial entity related tothe subject of this article.
Supplementary data
Supplementary data related to this article can be foundonline at http://dx.doi.org/10.1016/j.jse.2013.01.023.
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