summary Total Elbow Arthroplasty (TEA) is an increasingly used motion-preserving modality for the treatment of many debilitating elbow pathologies. Primary indications include rheumatoid arthritis, post-traumatic arthritis, and intra-articular distal humeral fractures in the elderly with poor bony quality. Semiconstrained implants have the best longevity and most optimal functional outcomes. Epidemiology TEA for trauma is one of the fastest-growing indications Etiology Forms of elbow arthroplasty total elbow arthroplasty hemi elbow arthroplasty radiocapitellar distal humeral ulnohumeral distraction & interpositional arthroplasty olecranon fossa debridement radial head arthroplasty Indications Indications rheumatoid arthritis (RA) indication 10-20% of patients with RA will have arthritic changes in the elbow TEA considered for Larsen stages 3 to 5 with: functional loss pain instability ideally, patient should be older than 65 years old outcomes longest survivorship when TEA is performed for RA compared to other indications most reliable with advanced, refractory RA primary osteoarthritis (advanced) indication patient should be older than 65 years old mid-arc pain with activity resulting from ulnotrochlear joint cartilage loss outcomes 10-year implant survival about 80-85% for TEA for primary OA fracture indication physiologically elderly patient (e.g., > 70 years) with: acute complex, unreconstructable intra-articular distal humerus fracture missed elbow fracture dislocation poor quality bone outcomes faster recovery with more predictable functional outcomes compared to fixation strategies limitations of lifting weight more than 5 to 10 pounds to avoid implant loosening posttraumatic osteoarthritis (advanced) chronic instability Contraindications absolute active infection (arthrodesis favored) Charcot joint relative poor neurologic control of affected extremity active patient younger than <65 years old olecranon osteotomy Implants Designs unconstrained or unlinked components example Ewald capitello-condylar design technical aspects requires competent collateral ligaments and soft tissue envelope requires good bone quality outcomes instability is most common complication (5-10% dislocation) precise component alignment is required no proven superiority or clear indication compared with semiconstrained/linked semiconstrained or linked components examples Coonrad-Moorey design technical aspects "sloppy hinge" allows for some varus-valgus and rotational laxity reduces stress on bone-cement interface, which reduces incidence of component loosening outcomes best results of all the designs complication of early humeral loosening with designs without an anterior flange constrained example Dee design technical aspects rigid hinged design theoretically most stable design (versus unlinked) outcomes highest loosening rates compared to semiconstrained and unconstrained designs Design pearls component stems (ulna and humerus) have improved fixation and reduced loosening humeral component extracortical anterior flange resists posteriorly directed and rotational forces radial head not needed for stability in linked TEA designs radial head often debrided or resected in RA, due to mechanical symptoms or pain Key Technical Concepts Preoperative care clinical evaluation age > 65 low demand patient able to comply with post-operative weight-bearing restriction (none do so be careful who you operate on) medical optimization imaging standard radiographs AP and lateral views of elbow assess bone stock ensure medial and lateral columns are intact assess canal diameter for implant design cervical spine flexion-extension views rheumatoid arthritis patients CT scan Surgical positioning supine arm draped free requires an assistant to hold the arm over the patients chest surgeon must take care to avoid the endotracheal tube lateral decubitus arm positioned over a bolster minimizes the need for an assistant to hold arm decreases the ability to manipulate the arm approach triceps-reflecting, triceps-splitting, and triceps-sparing triceps-reflecting (Bryan-Morrey) triceps reflected from medial to lateral in continuity with the anconeous triceps re-attached to ulna with nonabsorbable suture through bone tunnels There can be associated weakness or loss of elbow extension due to the detachment of the triceps brachii insertion from the olecranon. triceps tongue raise fascial tongue from olecranon back proximally release collateral ligaments proximally and distally can be used for fractures or TEA triceps-splitting triceps is longitudinally divided in continuity with forearm fascia over dorsal ulna triceps can also be split proximally with a V-shaped turndown of the tendon, leaving insertion onto olecranon intact allows for extensor mechanism lengthening if needed triceps-sparing triceps preserved intraoperatively, but exposure can be challenging medial and lateral borders of triceps are mobilized best for using TEA to manage acute distal humerus fractures allows for earlier post-op range of motion triceps "on" direct midline, posterior incision identify, release and protect the ulnar nerve release the flexor-pronator mass and medial collateral ligament from medial epicondyle elevate the triceps off the posterior humerus towards the lateral intermuscular septum release the common extensors and lateral collateral ligament complex disarticulate the ulno-humeral joint technique bone preparation preparation of humeral component resect the olecranon fossa of distal humerus keep medial and lateral column intact broaching to appropriate sized component preparation of ulnar component resect the olecranon tip of proximal ulna resect tip of coronoid to avoid impingement on anterior flange which will cause axial pistoning of ulna and loosening broaching to appropriate sized component implant insertion component design semiconstrained most common modern cement preparation and technique humerus component prepare a wedge-shaped piece of bone for placement behind the humeral flange maintain component orientation relative to the posterior flat surface of the distal humerus ulnar component orient the implant perpendicular to the dorsal flat surface of the olecranon Postoperative care early period of immobilization early motion after TEA is classically associated with wound complications, instability, and hardware loosening newer evidence supports a variety of post-operative immobilization protocols overall complications lower with earlier range of motion implant survival rates higher with prolonged immobilization lifelong weightlifting restriction of less than 5-10 lbs Outcomes Rheumatoid arthritis TEA outcomes 10 year survivorship 92.4% rate of survivorship free of revision at 10 years however very high complication rate (14%) triceps avulsion deep infection periprosthetic fracture aseptic loosening Post traumatic arthritis TEA outcomes 5 year survivorship most achieve functional ROM and patient satisfaction high complication rate (27-43%) high re-operation rate (25%) Complications Aseptic loosening (radiographic 17%, clinical 6%) most common mode of failure for constrained Infection (8%) acute infection (< 30 days) treatment aggressive serial irrigation and debridement and antibiotic bead placement success depends on organism staphylococcus epidermidis is associated with persistent infection because it is an encapsulating organism, and it is best treated with implant removal and IV antibiotic chronic infection treatment two staged reimplantation versus resection arthroplasty in medically ill patients or those with inadequate bone stock. Instability (7-19%) most common mode of failure for semiconstrained Bushing wear (obtain AP xrays and varus/valgus angle of > 10 degrees is concerning) common mode of failure for constrained Wound healing (higher with longterm steroid use) Ulnar neuropathy Triceps insufficiency Bone loss from multiple revisions, fractures, osteolysis graded based on humeral bone stock treatment up to 8cm of distal humeral loss can be replaced with longer prosthesis with extended anterior flange or endoprosthesis (total humerus) salvage options include flail elbow, amputation, arthrodesis Periprosthetic fracture in 5-30% of primary TEAs causes trauma osteoporosis aseptic loosening stress shielding poor technique non compliance with activity restriction classification based on that for periprosthetic femoral fractures (see table below) Mayo (O'Driscoll & Morrey) Classification of Periprosthetic fracture Characteristics Treatment Type I Periarticular fracture involving the humeral condyle or olecranon. Caused by osteolysis around hinge components and distracting forces from muscle attachments Undisplaced - Immobilization /soft tissue repair is sufficient to achieve fibrous union (Rigid fixation not required). Displaced - ORIF with heavy nonabsorbable sutures or tension band wiring (if limited periprosthetic bone) Type II Fracture along length of humeral or ulnar stem. Subtypes: II1: well-fixed implant II2: loose implants, good bone stock II3: loose implants, severe bone loss I1: ORIF with component retention +/- strut allograft II2: Revision arthroplasty using long-stem prosthesis ± strut allograft and impaction bone grafting. Locking plates/ cerclage wires may be added for added stability. II3: Require revision arthroplasty with extensive allograft supplementation. Often times require resection arthroplasty Type III Distal to prosthesis. Treated like routine fractures. Radiographs/CTs to ensure implants are not loose, cement mantle not cracked. If implants are well-fixed, immobilization for humerus and ORIF for ulna. If implants are loose, treat as Type II2 fractures.