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Updated: May 28 2022

Partial Elbow Arthroplasty

Images arthroplasty_moved.jpg head excision_moved.jpg
  • Introduction
    • Forms of elbow arthroplasty
      • total elbow arthroplasty
      • elbow hemiarthroplasty
        • radiocapitellar
        • distal humeral (not FDA approved)
      • ulnohumeral distraction & interpositional arthroplasty
      • ulnohumeral debridement arthroplasty
      • radial head excision
      • radial head arthroplasty
  • Elbow Hemiarthroplasty
    • Introduction
      • non-FDA approved hemiarthroplasty of either radiocapitellar joint or distal humerus
      • thought to avoid capitellar degeneration
  • Ulnohumeral Arthroplasty (distraction interposition)
    • Introduction
      • resection followed by contouring of articular surfaces with fascial interposition
      • addition of distraction external fixator allows early motion
    • Indications
      • young active patients with posttraumatic arthritis too young to follow TEA restrictions
      • ligamentously stable elbow
    • Approach
      • posterior midline skin incision
      • Kocher's interval
      • extensor musculature and LUCL complex released
      • if aconeus is to be used, release ulnar attachment
      • triceps released from lateral olecranon attachment, ulnar subluxated and elbow flexed to expose distal humerus
    • Bone work
      • distal humerus and ulnar surfaces prepared with saw or rongeur to create congruent surface
      • all osteophytes and cartilage removed to expose subchondral bone
    • Soft tissue
      • ulnar nerve transposed if symptomatic or prone to subluxate
      • capsular release performed to address contractures
    • Instrumentation
      • local aconeus autograft, tensor fascia autograft or Achilles allograft interposed in joint, sutured into place to cover distal humerus
      • graft may be pulled through bone tunnels to address collateral insufficiency
      • hinged external fixator placed to distract joint and allow early motion
    • Complications
      • bony resorption, joint subluxation, heterotopic ossification
    • Outcomes
      • less predictable than TEA
      • reasonable pain relief achieved in short-term and intermediate-term
      • worse outcomes if residual instability present
  • Ulnohumeral Debridement Arthroplasty¬†(Outerbridge-Kashiwagi procedure)
    • Indications
      • joint space narrowing
      • osteophytes (especially in posteromedial olecranon)
    • Approach
      • arthroscopic debridement for mild disease and no prior ulnar nerve transposition
      • open debridement for severe disease with inaccessible joint space
        • posterior triceps-splitting approach
        • lateral column approach allows better access to anterior joint
    • Bone work
      • osteophytes and soft tissues removed from olecranon tip and fossa
      • olecranon fossa opened with burr or trephine to access coronoid fossa
      • osteotome to resect coronoid osteophytes
    • Soft tissue
      • capsular release may be done in conjunction if contracture present
      • generally the ulnar nerve is transposed if pre-operative range of motion less than 90 degrees
    • Complications
      • lesser outcomes with failure to release all causative osteophytes
      • failure to recognize and address ulnar neuropathy with release or transposition leads to inferior outcomes
    • Outcomes
      • improvements in motion and pain with both arthroscopic and open procedures
  • Radial Head Excision
    • Indications
      • rheumatoid arthritis isolated to the radiocapitellar joint
      • unreconstructable radial head fracture in ligamentously stable elbow
    • Approach
      • performed using either Kocher or Kaplan's interval
      • supinator muscle fibers and capsule split longitudinally
    • Bone work
      • resect any bony fragments
      • resect as little radial neck as possible
      • use fluoroscopy to evaluate stability of elbow and distal radioulnar joint following resection
    • Instrumentation
      • none
    • Complications
      • progressive degenerative changes in ulnohumeral joint of unclear significance
      • radial shortening and wrist pain, likely secondary to unrecognized interosseous injury
    • Outcomes
      • increase in valgus elbow carrying angle
  • Radial Head Arthroplasty
    • Indications
      • unreconstructable radial head fracture
      • radial head malunion or nonunion
      • radiocapitellar arthritis
    • Approach
      • performed using either Kocher or Kaplan's interval
      • supinator muscle fibers and capsule split longitudinally
    • Soft tissue
      • LUCL complex may be taken down for visualization but must be repaired
    • Bone work
      • level of saw cut at the base of radial neck
      • proximal canal broached to anatomic fit
    • Instrumentation
      • size the native radial head if intact
      • trial implant to assess for gapping or overstuffing of joint
      • lesser sigmoid notch can serve as landmark if using fluoroscopy
      • assess fit in both extension and flexion
    • Complications
      • capitellar degeneration due to overstuffing joint
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