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. 2022 Sep 24;56(12):2029–2041. doi: 10.1007/s43465-022-00744-y

Total Elbow Arthroplasty from Indian Perspective: A Systematic Review

Vivek Tiwari 1, Samir Dwidmuthe 1,✉
PMCID: PMC9705626  PMID: 36507203

Abstract

Background

Total elbow arthroplasty (TEA) provides satisfactory pain relief and restores elbow range of motion and function in patients with end-stage arthritis. Due to advances in implant design and surgical techniques, the indications for surgery have expanded to include various other conditions affecting the elbow. The previous studies and systematic reviews reported satisfactory mid-term and long-term clinical outcomes after TEA with relatively stable complication and revision rates. However, there is lack of information in the literature about the results of TEA in Indian patients.

Methods

Two reviewers performed a comprehensive literature search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in three online databases—Pubmed/MEDLINE, Google scholar and the Cochrane database for clinical trials. Only original studies published in the English literature reporting outcomes of primary TEA in Indian patients were included for analysis. Using pre-defined inclusion and exclusion criteria, articles were screened and the relevant articles identified. Data were extracted with the primary objective to assess pain relief and functional outcome after TEA in Indian patients, and secondary objective to identify indications for surgery, complication rates and incidence of implant removals.

Results

A total of 212 TEAs (210 patients) from ten articles were included in this systematic review. All the TEAs were done using Baksi’s semi-constrained sloppy-hinged elbow prosthesis. The most common indication of TEA was post-traumatic sequelae (124 elbows, 58.5%), followed by comminuted intra-articular fracture distal humerus (53 elbows, 25%). At a weighted mean follow-up of 7.5 years, 80.7% cases had complete pain relief. The weighted mean flexion, extension restriction, supination and pronation were 122.6°, 20.8°, 57.3°, and 48.6°; respectively. The weighted mean Mayo Elbow Performance Score was 92.1 points with excellent outcome. Overall, a total of 68 complications were reported (32%) and the implants needed to be removed in 14 elbows (6.6%) including two revisions.

Conclusions

This systematic review found that the functional outcome and pain relief obtained with TEA using Baksi’s sloppy-hinged prosthesis in Indian patients were satisfactory overall. The complication rates and implant removal rates were lower than those reported with other patient populations.

Keywords: Elbow replacement, Total elbow arthroplasty, Indian patients, Baksi elbow prosthesis, Elbow arthritis

Introduction

Degenerative conditions of the elbow joint cause significant disability to patients considering its crucial role as a fulcrum in upper limb activities. Total elbow arthroplasty (TEA) has been developed, evolved and practiced in the last five decades as a breakthrough management option for such elbows where other surgical options fail. The first major reported use of modern TEA dates back to early 1970s when Dee et al. published promising early results using a hinged elbow prosthesis for patients with rheumatoid arthritis [1]. Ever since, there has been large-scale research and advancements in the types of TEA implants as well as its surgical technique. Consequently, the indications for surgery have expanded to include various other conditions affecting the elbow. A recent systematic review reported satisfactory long-term clinical outcomes after TEA with relatively stable complication and revision rates [2]. However, there is lack of information in literature about the results of TEA in Indian patients. As the proportion of population engaged in manual labor and strenuous physical activity is higher in India than the western world, considering a large proportion engaged in agriculture, the results of TEA in Indian patients may be different from that seen in developed nations. Therefore, we performed this systematic review to evaluate the outcomes of TEA in Indian patients. The primary objective of the review is to report pain relief and functional outcome, assessed using elbow range of motion (ROM) measurements and specific elbow outcome scores, after TEA. The secondary objective is to summarize indications for surgery, complication rates and incidence of implant removals.

Materials and Methods

Literature Search

A comprehensive literature search was done by two reviewers using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines in three online databases- Pubmed/MEDLINE, Google scholar and the Cochrane database for clinical trials. The MeSH terms used for search included “arthroplasty”, “replacement” and “elbow”. The other search terms included “total elbow arthroplasty”, “total elbow replacement”, “elbow replacement”, “distal humeral reconstruction”, “India” and “Indian patients”. Considering a relatively smaller number of relevant articles expected, no time limit was applied for the search. The search results were independently scanned by the two reviewers on the basis of title, abstract and author affiliations to identify relevant articles. The references of these articles were also checked manually to avoid missing any related articles. Full text was evaluated for these identified articles and the two authors then independently selected articles for analysis, using pre-defined inclusion and exclusion criteria. In cases of doubts or discrepancy regarding selection of article, the two authors then met to solve the dilemma by mutual discussion.

Inclusion and Exclusion Criteria

Only original studies reporting outcomes of primary TEA in Indian patients were included for analysis. The indications for surgery included rheumatoid arthritis, post-traumatic sequelae, fresh distal humeral fractures, elbow ankylosis and tubercular arthritis. We only included those studies having minimum 5 patients and a minimum reported follow-up of 1 year. The articles on use of TEA for tumors around elbow were excluded. We also excluded articles reporting results of radial head replacement, excisional arthroplasty, resection arthroplasty or interposition arthroplasty. All other articles except original articles including case reports, review articles, opinions, letters, surgical techniques and studies evaluating failed procedures were excluded. We also excluded Abstract-only original articles where full text was not available. We only included articles published in English language.

Data Extraction

The two reviewers extracted data from the selected articles, identified after application of inclusion and exclusion criteria. The primary objective was to assess pain relief and functional outcome obtained after TEA in Indian patients; functional outcome was evaluated using ROM measurements and specific elbow outcome scores. The secondary objective was to identify indications for surgery, complication rates and incidence of implant removals. Data extracted included demographic data like age and sex; number of patients and elbows operated; type of implant used; and follow-up in years. The indications for surgery were also recorded (eg: rheumatoid arthritis, distal humeral fractures, ankylosis, post-traumatic sequelae, or any other elbow disease). The outcome parameters assessed were occurrence of pain, and functional outcome obtained, assessed using ROM measurements and specific elbow outcome scores. Also, incidence of different complications like superficial and deep infection, aseptic loosening, periprosthetic fracture, intra-operative fracture, ulnar nerve palsy, triceps weakness, implant failure and heterotopic ossification/myositis were also recorded, when available. Data were also collected regarding number of cases requiring implant removal/revision. In the selected articles, we also looked for incidence of revision TEA and implant survival data assessed using Kaplan–Meier survival analysis, where available.

Quality of Studies

We evaluated the methodological quality of the included articles by assigning levels of evidence, given by the Center for Evidence Based Medicine. The two authors independently evaluated and assigned the levels of evidence to the selected articles. Afterwards, the two authors met and discussed regarding their individual findings to arrive at a consensus regarding the levels of evidence assigned.

Statistical Analysis

After extraction of data from the selected articles, groups were made on the basis of indication for surgery. Descriptive analysis was done wherein continuous data were expressed as numbers and percentages, and categorical data were expressed as percentages. Weighted means were calculated for age, male sex percentage, ROM measurements, MEPS scores, and follow-up. Functional outcome was evaluated overall as well as according to different indications for surgery, and was assessed by ROM measurements and MEPS scores. Similarly, complication rates and implant removal rates were assessed according to different indications for surgery.

Results

Articles

The comprehensive literature search using the three online databases mentioned previously yielded 5840 articles. After the initial screening done by two independent reviewers using title, abstract and author affiliations, 5810 articles were excluded. The full text of the remaining 30 articles was evaluated, and ultimately 10 articles were included in the systematic review [3–12]. Relevant data were extracted from these 10 selected articles (Fig. 1). We included only 10 patients (out of 11) from the Kumar et al. study in analysis, as 1 patient had follow-up of less than 1 year [6]. All the studies included in the analysis were case-series with level of evidence IV.

Fig. 1.

Fig. 1

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The PRISMA flow-chart

Implant Type and Indications for Surgery

A total of 212 TEAs (210 patients) were included in this systematic review. The weighted mean age was 43.3 years (203 patients) and the weighted mean percentage of male patients was 45.5%; one study [11] did not report the mean age of the patients. Only one study described two patients with bilateral TEA, rest all the patients underwent unilateral TEA. All the TEAs were done using Baksi’s semi-constrained sloppy-hinged elbow prosthesis.

Eight studies described the use of a posteromedial incision in the supine position (described by Baksi et al.), while two studies described Bryan Morrey’s triceps elevating approach. All the studies described radial head excision as part of the TEA. The most common indication of TEA was post-traumatic sequelae (58.5%). The different post-traumatic conditions included post-traumatic fibrous ankylosis (46 TEAs, 21.7%), non-union fracture distal humerus (28 TEAs, 13.2%), post-traumatic bony ankylosis (24 TEAs, 11.3%), old side-swipe elbow injuries (14 TEAs, 6.6%), post-traumatic arthritis (5 TEAs, 2.4%) and others (7 TEAs, 3.3%). The other indications for TEA were non-reconstructible comminuted intra-articular distal humerus fractures (25%), post-burn bony ankylosis (8%), rheumatoid arthritis (7.6%) and tubercular arthritis (1%). The different indications of TEA with their weighted mean age and weighted mean male percentage are depicted in Table 1.

Table 1.

Indications for TEA and the number of elbows operated

S. no. Indication for surgery No. of articles No. of elbows (N = 212) Mean weighted age (years) Male sex (weighted percentage)
1. Rheumatoid arthritis [6−8] 3 16 (7.6%) 42.5 25
2. Fracture distal humerus [5−7, 9, 11, 12] 6 53 (25%) 65a 38.8b
3. Post-traumatic sequelae [3, 5–7, 10, 11] 6 124 (58.5%) 36.3a 54.7b
4. Tubercular arthritis [7] 1 2 (1%) 46.5 50
5. Post-burn ankylosis [4, 6] 2 17 (8%) 31.7 26.7
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aThe weighted mean age was calculated from 5 studies; reference [11] was excluded as the mean age was not reported

bThe weighted male sex percentage was calculated from 4 studies; references [5, 11] were excluded as male sex percentages were not reported for these indications

Pain Relief and Functional Outcome

Nine out of the 10 studies reported pain evaluation [3–8, 10–12]. The elbow was painless in 80.7% of cases at a weighted mean follow-up of 7.45 years.

The weighted mean flexion obtained was 122.6°, and the weighted mean extension restriction was 20.8°. The weighted mean supination was 57.3°, and the weighted mean pronation was 48.6°. The functional outcome was reported using Mayo Elbow Performance Score (MEPS) [13] in nine studies [4–12]. The weighted mean MEPS was 92.1 points, considering it as an excellent score (≥ 90) [13]. The functional outcome obtained after TEA according to different indications is provided in Table 2. The weighted mean flexion–extension arc of motion was lowest (less than 100°) in post-burn bony ankylosis patients, whereas the weighted mean supination/pronation movements were lowest in patients operated for post-traumatic sequelae. Also, the weighted mean MEPS score was lowest for patients operated for post-burn bony ankylosis.

Table 2.

Indications for TEA and Functional outcome (weighted ranges of motion in degrees and Mayo Elbow Performance Scores)

S. no. Indication for surgery No. of elbows (N = 212) Flexion (no. of patients) Extension restriction (no. of patients) Supination (no. of patients) Pronation (no. of patients) MEPS
1. Rheumatoid arthritis [6−8] 16 122 10 63 (3)a 73 (3)a 86.2
2. Fracture distal humerus [5−7, 9, 11, 12] 53 123.4 (31)b 20.8 (18)c 65 (17)d 61.5 (17)d 95.7 (52)e
3. Post-traumatic sequelae [3, 5–7, 10, 11] 124 120.4 (98)f 21.8 (98)f 53.2 (97)g 37.1 (97)g 90.9 (39)h
4. Tubercular arthritis [7] 2 115 12.5 – – 90
5. Post-burn bony ankylosis [4, 6] 17 109.8 21.2 70 (1)i 70 (1)i 70 (1)i
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MEPS Mayo Elbow Performance Score

aThe weighted mean supination and pronation were calculated from reference [6]

bThe weighted mean flexion was calculated from 4 studies; references [5] and [11] were excluded

cThe weighted mean extension restriction was calculated from 3 studies; references [5, 9, 11] were excluded

dThe weighted mean supination/pronation were calculated from 2 studies; references [5, 7, 9, 11] were excluded

eThe weighted mean MEPS was calculated from 5 studies; reference 11 was excluded

fThe weighted mean flexion/extension restriction were calculated from 4 studies; references [5, 11] were excluded

gThe weighted mean supination/pronation were calculated from 3 studies; references [5, 7, 11] were excluded

hThe weighted mean MEPS was calculated from 4 studies; references [3, 11] were excluded

iThe supination, pronation and MEPS values were reported from reference [6] only

Complications and Implant Removals

Overall, a total of 68 complications were reported for 212 TEAs (32%). Infection was reported in 26 elbows (12.3%) including 11 deep infections (5.2%). Aseptic loosening was seen in 15 elbows (7.1%), and 13 elbows reported ulnar nerve palsy (6.1%) all of which were transient. Seven cases reported heterotopic ossification (3.3%), four TEAs reported arm length discrepancy (1.9%), fractures were seen in three elbows (1.4%) including two cases of intra-operative fracture of ulna. Other complications included implant failure in two elbows, haematoma requiring drainage in two elbows, triceps weakness in one and tourniquet palsy in one case. No case of elbow dislocation was reported in any of the articles.

Table 3 depicts complications and implant removals seen after TEAs for different indications. Patients with post-burn bony ankylosis had the highest number of complications (11 elbows, 65%) at a weighted mean follow-up of 13.9 years. Also, the implant removal rate was highest in those subsets of patients (6 cases, 35%). Overall, the implants needed to be removed in 14 elbows (6.6%). Out of them, only two cases underwent revision total elbow arthroplasty; rest of the cases were subjected to resection arthroplasty with fair outcome. No studies reported about Kaplan Meier survival analysis of implants; hence survival data could not be provided. The patient characteristics from the ten studies included in this review are tabulated in Table 4.

Table 3.

Complications and Implant removal/revision after TEA for different indications

S. no. Indication for surgery No. of elbows (N = 212) Complications (N = 68, 32%) Weighted follow-up (years) No. of implant removals/revision
1. Rheumatoid arthritis [6−8] 16 3 (19%) 5.3 –
2. Fracture distal humerus [5−7, 9, 11, 12] 53 14 (26%) 1.4a 1 (2%)
3. Post-traumatic sequelae [3, 5–7, 10, 11] 124 39 (31%) 9.4a 7 (1 revision) (6%)
4. Tubercular arthritis [7] 2 1 (50%) 1 –
5. Post-burn ankylosis [4, 6] 17 11 (65%) 13.9 6 (1 revision) (35%)
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aThe weighted follow-up was calculated from 5 studies; reference [5] was excluded

Table 4.

Patient characteristics from the ten studies included in the systematic review

S. no. Article Study type Level of evidence No. of patients Mean age in years (range) No. of male/female patients (male percentage) Indication of surgery (no. of patients) Mean follow-up (years) Pain (no. of patients) ROM (no. of patients) Functional outcome Complications (no. of patients) Implant removal
1. Baksi (1998) [3] Retrospective Case series IV 79 28.6 (17–70) 43/36 (54%) Elbow ankylosis (68 patients—22 bony ankylosis, 46 fibrous ankylosis), Post-traumatic instability (11 patients—5 non-union fracture distal humerus, 3 failed excision arthroplasty, 3 old open injuries with bone loss) 9.6 None (70), Occasional (6), Constant (3) F: 115°, E: 27°, S: 57°, P: 35° (Ankylosed elbows); F: 140°, E: 15°, S: 63°, P: 41° (post-traumatic instability) 54 good, 8 fair, 6 poor (out of 68). 9 good, 1 fair, 1 poor (out of 11) 14 cases (20): Infection (7), aseptic loosening (4), implant failure (1), transient ulnar nerve palsy (4), intra-op ulna fracture (1), myositis (2), periprosthetic fracture (1) 4—3 infection, 1 implant failure
2. Baksi et al. (2009) [4] Retrospective Case series IV 14 (16 elbows) 31.6 (21–48) 4/10 (29%) Post-burn bony ankylosed elbows 14.1 None (11) F: 108° (11), E: 20° (11), MEPS: 9 excellent, 2 good, 5 poor 10—Superficial infection (4), Deep infection (2), Ulnar neuropraxia (2), Aseptic loosening (1), Myositis (1) 5—1 infection, 2 aseptic loosening, 2 nonrecovery of active contraction of muscles
3. Baksi et al. (2011) [5] Retrospective Case series IV 41 58 (56–78) 17/24 (41%) Intercondylar fracture humerus (21 fresh and 20 non-union) 4.6 None (39), Moderate (2) F: 130° (39), E: 25° (39), S: 60° (33), P: 65° (33) MEPS: 96 points- 19 excellent, 1 good, 1 poor (fresh fracture), 94 points- 17 excellent, 2 good, 1 poor (non-union group) 11—Superficial infection (2), deep infection (2), transient ulnar neurapraxia (3), implant failure (1), heterotopic ossification (2), aseptic loosening (1) 3—2 infection, 1 implant failure (1 revision)
4. Kumar et al. (2013) [6] Retrospective Case series IV 10 53 (28–69) 3/7 (30%) Rheumatoid arthritis (3), comminuted fracture distal humerus with intra-articular extension (2), post-traumatic bony ankylosis (2), post-burn ankylosis (1), non-union fracture distal humerus (1), malunited fracture distal humerus with non-union fracture proximal ulna (1) 5 None (9) F: 133°, E: 13°, S: 70°, P: 73° MEPS: 95 points (range 70–100) 9—Ulnar stem loosening (2), arm length discrepancy (4), superficial infection (1), myositis (2) 1—aseptic loosening (1 revision)
5. Handralmath et al. (2015) [7] Retrospective Case series IV 5 54 (35–70) 2/3 (40%) Tubercular arthritis (2), rheumatoid arthritis (1), non-union fracture distal humerus (1), comminuted distal humerus fracture (1) 1 None (5) F: 118°, E: 14° MEPS: 91 points (range 85–95), 4 excellent, 1 good 1—Intra-operative fracture of ulna (1) –
6. Balaji et al. (2016) [8] Retrospective Case series IV 12 38.6 (20–60) 4/8 (33%) Rheumatoid arthritis 6 None (8), Mild (3), Moderate (1) F: 120°, E: 10° MEPS: 82.91 points (range 55–95), 2 excellent, 9 good, 1 fair 3—Superficial infection (1), Implant loosening (2) –
7. Ghosh et al. (2016) [9] Retrospective Case series IV 13 70.8 (66–78) 4/9 (31%) Comminuted distal humerus fracture in elderly 1.6 – F: 115°, S + P: 161° MEPS: 93.84 points (range 85–100), 10 excellent, 3 good 6—Deep infection (1), superficial infection (1), transient ulnar nerve palsy (2), transient tourniquet palsy (1), aseptic loosening (1) –
8. Baksi et al. (2018) [10] Retrospective Case series IV 14 42.7 (32–61) 9/5 (64%) 2–3 years old side-swipe injuries 13.5 None (11) F: 130° (10), E: 0° (10), S: 22°, P: 35° MEPS: 84 points, 5 excellent, 6 good, 1 fair, 2 poor 9—Deep infection (2), superficial infection (2), aseptic loosening (4), transient ulnar nerve palsy (1) 2—infection
9. Swamy et al. (2018) [11] Retrospective Case series IV 7 (50–80) 4/3 (57%) Post-traumatic arthritis (5), comminuted distal humerus fracture (1), fracture non-union distal humerus (1) 2 None (3), Mild (3), Moderate (1) F: 130°, E: 10°, S: 78°, P: 85° MEPS: 90 points – –
10. Behera et al. (2018)12 Prospective Case series IV 15 61.5 (53–73) 6/9 (40%) Intra-articular distal humerus fracture 1 None (15) F:130°, E:22°, S:63°, P: 59° MEPS: 97.3 points (range 80–100), 14 excellent, 1 good 5—Superficial infection (1), transient ulnar neuropraxia (1), post-operative hematoma requiring drainage (2), triceps weakness (IV/V) (1) –
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Discussion

TEA provides pain relief and restores elbow range of motion and function in patients with end-stage arthritis. Previously, it was advised to patients suffering with severe rheumatoid arthritis where the other surgical options failed. However, with technical advancements enabling refinements in the design and type of elbow prosthesis, improvements in surgical technique and enhanced expertise of the surgeons, the indications of surgery have expanded to include primary elbow osteoarthritis [14], post-traumatic sequelae [3, 5–7, 10, 11, 15–17], non-reconstructible comminuted distal humerus fractures [5–7, 9, 11, 12, 18–21], other inflammatory arthritides [22], hemophilic arthropathy [23, 24] and tumors around elbow [25, 26]. The functional outcomes and complications of TEA have been reported in previous systematic reviews to foster evidence-based medicine [2, 27, 28]. However, there is lack of such data on results of TEA in Indian patients, a population comprising a substantially higher-proportion of people engaged in strenuous physical activities, and where patients with elbow pathologies often present quite late to the orthopedic surgeons with significantly advanced disease and joint destruction. The current systematic review, was performed to bridge this knowledge-gap to summarize the indications for surgery, pain relief and functional outcome obtained, complications encountered and implant removal rates in Indian patients undergoing TEA. To the best of our knowledge, this is the first systematic analysis of TEA patients from India. Two hundred and twelve TEAs (210 patients) were analyzed in the current systematic review from 10 articles. All the studies included in the review were case-series with level IV evidence. As the various outcome measures were not uniformly reported in all studies, comparison was often difficult.

Implant Type and Indications for Surgery

In the current review, Baksi’s semi-constrained sloppy-hinged prosthesis was used in all the studies. This indigenous, low-cost, all-metal, linked prosthesis was first developed in 1977 as a rigid hinged prosthesis. After reports of higher chances of aseptic loosening of rigid hinged implants at bone cement interface came out, and after extensively testing this implant in an elbow joint simulator, a modified version of Baksi’s prosthesis (the sloppy-hinged prosthesis) was developed in 1983 which allowed 7°–10° of varus/valgus laxity, thereby decreasing stress at bone cement interface. This implant was redesigned in 2003 to decrease the rotational stress in the humeral component, when two flanges were added to the shank of humeral stem which get fit in the dedicated slots made in coronal plane in the cut distal humerus [29].

Majority of the articles reported on TEA in fracture distal humerus and post-traumatic sequelae (6 articles each). The most common indication for surgery was post-traumatic sequelae (58.5%), followed by acute comminuted distal humeral fractures (25%). In a previous systematic review on outcomes of TEA after 10 years, Davey et al. reported that 74% of the patients underwent TEA for advanced rheumatoid arthritis [2]. In another review article, Welsink et al. reported rheumatoid arthritis to be the most common indication for TEA [27]. However, the pattern observed in this review agrees with the global shift in indication for TEA towards traumatic causes from the earlier reported predominance in rheumatoid arthritis patients [30]. Rheumatoid patients constituted only 7.6% of the TEAs in India. No patients were operated for hemophilic arthropathy or other inflammatory arthritides. One study reported on TEA in two patients with tubercular arthritis, with start of anti-tubercular therapy 2 weeks before surgery and its continuation for one-year post-operatively [7]. Asopa et al. reported two-staged revision total elbow arthroplasty in a patient who developed tubercular arthritis post TEA [31]. However, there is no other literature available on primary TEA in tubercular elbow arthritis from western world. Similarly, two studies reported on results of TEA in post-burn bony ankylosis patients [4, 6]. This indication for TEA has not been mentioned in the western literature.

Pain Relief and Functional Outcome

Around 81% patients were found free from pain at a mean follow-up of 7.5 years in this study. Pain has been described in nearly 40% TEA patients at a mid-term follow-up of 6.3 years [27]. Moreover, around 36% patients had residual pain at a minimum mean follow-up of 10 years [2]. Thus, TEA using Baksi’s sloppy-hinged prosthesis provided greater pain relief in Indian patients. However, this outcome is still inferior than that seen after primary shoulder, hip and knee joint replacements [32–34]. Moreover, as 19% patients still had some pain in current review, patients need to be informed of these statistics about possibility of pain to make informed decisions before undergoing TEA.

The weighted mean flexion–extension arc of motion was found from 21° to 123°, and supination/pronation movements were from 57° to 49°. Thus, the ROM obtained was corresponding to the biomechanically acceptable standards of 100-degree flexion–extension arc and 100-degree pronation/supination arc of motion [35]. Similar ROM findings were reported at mid-term and long-term follow-ups in literature [2]. [27]. The flexion range obtained in post-burn patients (110°) was relatively lower than for other indications. Also, extension lag in post-traumatic sequelae patients (22°) was higher than other patient indications. Similarly, supination/pronation was relatively lower (less than 100-degree arc) for patients with post-traumatic sequelae.

Overall, the weighted mean MEPS score obtained was 92 points, making it an excellent functional outcome. Comparing the different indications for surgery, excellent to good functional outcome were seen for all patient groups (MEPS 86–96), except post-burn patients (MEPS 70) who had a fair outcome, probably due to extensive soft-tissue damage expected in these patients. Functional outcome in rheumatoid patients was reported to be better than trauma patients [36–40]. However, the MEPS scores in fresh fractures (96) and post-traumatic sequelae (91) were higher than rheumatoid patients (86) in our review. Similar to our results, Fritsche et al. also reported good clinical outcomes at mid-term follow-up after TEA in acute trauma condition [41].

Complications and Implant Removals

The overall complication rate in this review was found to be 32%. This data matched with that from previous literature which reports 10–45% complication rates after TEA [27, 42], except post-burn patients who showed complication rate of 65% at mean follow-up of 14 years. Infection constituted the most frequent complication (12%), followed by aseptic loosening (7%). The frequency of ulnar nerve involvement was 6%, and heterotopic ossification was seen in 3% TEAs. The rate of aseptic loosening in current review was almost half that described in previous studies at medium-term and long-term follow-up (13–16%) [2, 18]. [42]. The rates of aseptic loosening in Indian patients were similar to that reported by Welsink et al. (7%). However, the reported rates of deep infection (5.2%) and ulnar nerve palsy (6%) in Indian patients were higher than the previous reported literature [27]. The higher complication rates found in the Indian studies may be partially explained by the inclusion of post-burn ankylosis patients who had a relatively poor outcome. No case of elbow dislocation was reported as all the TEAs used linked prosthesis.

The implant removal rates (14 elbows, 6.6%) found in this review were substantially lower than the other studies (14%) [2, 27]. Only two TEAs were revised out of those with the rest subjected to resection arthroplasty with good results. In a retrospective analysis of 18 failed TEAs, Pal et al. reported acceptable clinical outcomes after resection arthroplasty with MEPS 70 at 15 years follow-up [43]. Survival data for implants could not be assessed as none of the studies reported Kaplan Meier survival analysis.

This systematic review had many limitations, mostly those related to selected studies. Firstly, all the studies included in analysis had level IV evidence. Hence, robust conclusions cannot be drawn from the results. However, this is the first comprehensive review of primary TEA in Indian patients, and will provide important information for evaluating the results of TEA with Baksi’s sloppy-hinged prosthesis in Indian population. Secondly, due to the lack of uniformity in data collection and reporting by the selected studies, summarization and standardization was difficult. Thirdly, differences in surgical techniques by the different surgeons could have confounded the results of the analysis, as functional outcomes and complications might vary with the surgical approach and the surgical technique. However, this review will provide detailed information regarding the status of TEAs in India, and will encourage the surgeons to improve the outcomes and also to conduct good-quality studies on primary TEAs. Also, a national registry on TEAs should be set-up in India, on the lines of hip and knee joint replacement registries, to assist in standardization of study data and to provide robust evidence for clinical pathways.

Conclusions

On comprehensive analysis of published literature in English language on TEA in Indian patients, this systematic review found that the functional outcome and pain relief obtained with TEA using Baksi’s sloppy-hinged prosthesis were satisfactory overall, with relatively less favorable results in post-burn bony ankylosis patients. The complication rates and implant removal rates were lower than those reported with other patient populations.

Author Contributions

VT contributed to conceptualization of the work and wrote the original draft; SD contributed to conceptualization of the work and writing-review and editing. All the authors approved the final version of the article.

Funding

The authors did not receive support from any organization for the submitted work.

Availability of Data and Material

Not applicable.

Code Availability

Not applicable.

Declarations

Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethics approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Footnotes

Publisher's Note

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References

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