Total Elbow Arthroplasty : Wheeless' Textbook of Orthopaedics

- Discussion:
- up to 80 % of patients w/ traumatic DJD may expect a good to excellent result at 5 years;
- up to 30 % of patients will sustain a major complication over 5 years, which often will require and additional operation;
- indications:
- end stage rheumatoid arthritis;
- severe intractable pain in association with severe grade 3,4,5
- major cysts at olecranon-coronoid junction, in association w/ severe grade 3-5 erosions;
- progressive loss of extension beyond 60 deg;
- instability which indicates very severe bone destruction and endangered ligamentous stability;
- fracture:
- comminuted humeral intercondylar fracture in patients over age 70;
- long term results may be unpredictable:
- references:
- Distal humeral fractures treated with noncustom total elbow replacement.
- Distal humeral fractures treated with noncustom total elbow replacement. Surgical technique.
- A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65.
- Primary total elbow replacement for fractures of the distal humerus.
- Total elbow arthroplasty for non-rheumatoid patients with a fracture of the distal humerus: a minimum ten-year follow-up.

- Preoperative considerations:
- if there is also significant RA involvement of the shoulder the question is which joint should be adressed first;
- many authors will prefer to perform the total elbow arthroplasty before the TSR;
- allows greater amount of time between arthroplasties and allows greater functional improvement;
- in addition w/ concomitant disease in both joints, it can be difficult to judge humeral retroversion (due to loss of
ligamentous contrainsts in elbow;
- need for semiconstrained prosthesis:
- patients who have had previous radial head resection and synovectomy (if unconstrained prosthesis is used);
- severe ligamentous laxity (if unconstrained prosthesis is used);
- more than 2 cm of distal humeral bone loss (may require customized prosthesis)
- references:
- Total elbow arthroplasty after previous resection of the radial head and synovectomy.
- Results of TEA after excision of the radial head and synovectomy in patients who had rheumatoid arthritis.

- Technique: (using the Coonrad-Morrey prosthesis - semiconstrained); (Discovery™ Elbow System)
    - posterior triceps reflecting approach:
          - tendon splitting approach: tendon insertion to the proximal ulna is elevated from the medial and lateral aspects of the ulna,
keeping the forearm fascia extending to the proximal ulna intact;
- alternatively, medial half of triceps is reflected along w/ posterior capsule, and the extensor mechanism is reflected laterally;
- ulnar nerve is identified and is transposed anteriorly;
          - ligamentous release:
                 - both collateral ligaments may be released off of epicondyles if a semiconstrained prosthesis is used (such
as semiconstrained modified Coonrad-Morrey);
- anterior capsule release:
- anterior capsule is released from the distal humerus to fully expose the joint and release any contracture;
- tip of the olecranon (and coronoid tip) is removed along w/ a portion of the MCL to gain better exposure;
- exposure is adequate when the lateral column is exposed;
- reference:
- The osteo-anconeus flap. An approach for total elbow arthroplasty.
- The Lateral Para-Olecranon Approach for Total Elbow Arthroplasty
- humeral preparation:
          - if humerus is prepared first then realize, then ulna is often smaller and may dictate sizing options;
- only the diaphysis is needed for secure fixation of the humeral component;
- deficiency or absence of an epicondyle should not be major problem;
- medullary canal is entered w/ a twist reamer and is exchanged for alignment stem w/ attached cutting block (placed radially);
- cutting block: set to remove an appropriate amount of distal humerus;
- consider seating the humeral component more proximal than usual to help relax the anterior soft-tissue envelope in extension
- ref: Effect of humeral condylar resection on strength and functional outcome after semiconstrained total elbow arthroplasty.
- controversies:
- cement vs press fit stems:
- in the report by Kudo H, et al (1999), the authors advocate press fit fixation with a circumferential plasma spray
fixation of the humeral component;
- humeral fixation with a concomitant shoulder arthroplasty:
- in report by Gill et al., the authors recommended filling IM canal with cement if the interval between the humeral
component stems is less than 6 cm);
- ref:
- Primary Souter-Strathclyde Total Elbow Prosthesis in Rheumatoid Arthritis.
- Ipsilateral total shoulder and elbow arthroplasties in patients who have rheumatoid arthritis.
- ulnar preparation:
- olecranon tip is removed to gain straight-line access to the canal;
- medullary canal is entered w/ a high speed drill;
- the previously removed olecranon tip facilitates entry into the canal;
- sequential rasping is performed w/ care to avoid proximal ulnar complication;
- broach parallel to the dorsal cortex to avoid malalignment;
- in the report by Kudo H, et al (1999), the authors advocate use of an all polyethylene cemented ulnar component;
- Primary Souter-Strathclyde Total Elbow Prosthesis in Rheumatoid Arthritis.
- cement insertion:
- consider adding one gram of tobramycin to the cement (see addition of antibiotics to cement)
- use a cement gun to insert cement;
- cement is allowed to harden w/ the elbow in extension;
- component insertion:
- ulnar component is articulated w/ the humeral component before the humeral component is seated;
- bone graft is placed behind the anterior humeral component falange;
- this helps the humerus resist posterior displacement and rotational displacement;
- remember that maximal stresses are found anteriorly at the insertion site of the humeral component, and that after bone
graft incorporates, thickened cortex will help resist these forces;
- humeral component is impacted down the medullary canal;
- ulnar component is inserted;
- wound closure:
- triceps should be reattached w/ intra-osseous sutures, which are inserted prior to component insertion;
- repair of the collateral ligaments is not necessary;
- consider maintaining the elbow in extension for 2-3 days in order to allow the soft tissues to heal;

- Complications:
- posterior elbow dislocation;
- may occur in approximately 10% of patients undergoing unconstrained arthroplasty;
- ulnar nerve dislocation;
- impingement of the radial head;
- proximal ulna fracture;
- hardware failure:
- worn bushings;
- fracture of ulnar component;
- infection:
- may range from 1 to 10%;
- in acute infection w/ non virulent organism (not staph epidermidis) approximately 50% of patients may expect successful
outcome from multiple debridements and retention of components;
- as a requirement for this technique all bushing need to be removed in order to allow a thorough washout;
- staged removal of components, debridements, and re-implantation of components will be successful in the majority of patients
if highly virulent organisms are not present (such as stap epidermidis);
- staph epidermidis infections are expected to recur if components are re-inserted;
- resection arthroplasty should result in the erradication of infection and will provided relatively high rates of patient
satisfaction (despite poor function);
- references:
- Management of infection about total elbow prostheses.
- Infection after total elbow arthroplasty.