Elbow Arthroplasty

Author: Daniel Hatch

Topic updated on 04/25/13 7:34pm

Introduction

Forms of elbow arthroplasty
- total elbow arthroplasty
- ulnohumeral distraction & interpositional arthroplasty
- olecranon fossa debridement
- radial head excision

Total Elbow Arthroplasty

Indications
- rheumatoid arthritis (RA)
  - highest survivorship when done for RA
  - reliable procedure for advanced, refractory RA
  - indications include pain, loss of motion, instability
  - Larsen stage 3 through 5
- primary osteoarthritis (advanced)
  - patient should be >65 years old
- posttraumatic osteoarthritis (advanced)
- fracture
  - complex intraarticular fracture in patient > 70 years
- chronic instability
Contraindications
- absolute
  - active infection (arthrodesis favored)
  - Charcot joint
- relative
  - poor neurologic control of affected extremity
  - active patient younger than <65 years old
Designs
- unconstrained or unlinked (e.g., Ewarld capitella)
  - requires competent collateral ligaments and good bone quality as stability supplied by the soft tissue
  - resurfacing arthroplasty
  - instability is most common complication (5-10% dislocation)
- semiconstrained or linked(e.g. Coonrad-Moorey)
  - "sloppy hinge" allows for some varus and valgus motion
  - best results of all of the designs
  - complication of early loosening
- constrained
  - increased loosening rates compared to semiconstrained devices
Technique
- approach
  - triceps splitting or sparing posterior approach
- transosseous nonabsorbable suture
- usually perform ulnar transposition
- radial head resection common
Postoperative care
- lifelong weightlifting restriction of 10 lb
Complications (as high as 43%)
- aspetic loosening (radiograhic 17%, clinical 6%)
- 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%)
- bushing wear (obtain AP xrays and varus/valgus angle of > 10 degrees is concerning)
- wound healing (higher with longterm steroid use)
- ulnar neuropathy
- triceps insufficiency

Ulnohumeral Arthroplasty (distraction interpositon)

Introduction
- resection followed by contouring of articular surfaces with fascia coverage
- some use distraction external fixator to allow early motion
Indications
- reasonable choice for young active patients with posttraumatic arthritis who are too young to have a TEA
Results
- results less predictable than TEA

Olecranon Fossa Debridement (Outerbridge-Kashiwagi procedure)

Indications
- joint space narrowing
- osteophytes (especially in posteromedial olecranon)
Limitations
- incomplete anterior release
- incomplete osteophyte removal anteriorly

Radial Head Excision

Indicationsrheumatoid arthritis with arthritis isolated to the radiocapitellar joint
Approach
- performed through lateral approach to the elbow

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Qbank (2 Questions)

TAG

(OBQ11.261) What is the preferred treatment for a propionibacterium acnes infection that has been symptomatic for 6 months after total elbow arthroplasty with well-fixed components, good bone stock, and a healthy patient? Topic

Review Topic

1. Non-operative treatment with IV antibiotics for 6 weeks
2. Arthroscopic irrigation and debridement
3. Open irrigation and debridement with poly exchange
4. Single stage revision arthroplasty
5. Two stage revision arthroplasty

PREFERRED RESPONSE ▶

DISCUSSION: Chronic propionibacterium acnes infections of elbow arthroplasty are best treated with two staged revision arthroplasty in healthy patients with adequate bone stock for reimplantation. The algorithm to treat infected total elbow arthroplasty depends on a number of factors including patient characteristics, bacteriology, duration of symptoms, and implant fixation/bone stock.

Yamaguchi et al discuss that poor health status or inadequate bone stock may indicate resection arthroplasty, while acute (<1 month) infections with staph aureus have a greater than 50% chance of success with debridement and retention of components. Most chronic infections or those caused by staph epidemidis or proprionibacterium acnes have high recurrence rates with retention and a two stage revision should be considered with antibiotic spacer and at least 6 weeks of IV antibiotics between staged procedures. Immeadiate reimplantation in a single stage is controversial and success rates range from 25-75% and are most successful in staph aureus infections.

REFERENCES:

1. Yamaguchi K, Adams RA, Morrey BF. Infection after total elbow arthroplasty. J Bone Joint Surg Am. 1998 Apr;80(4):481-91 PMID:9563377 (Link to Abstract)

2. Yamaguchi K, Morrey BF. Treatment of the infected total elbow arthroplasty. In: Morrey BF, ed. The Elbow and It's Disorders. 3rd ed. Philadelphia, PA: WB Saunders; 2000:678-684.

Question Authors:

Charles Jobin MD, Patrick McCulloch MD, Ben Taylor MD,

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Videos

	Talk on Elbow Replacement - Dr. Mark Vitale Sports - Educational Presentation - Elbow Arthroplasty Podium presentation on elbow replacements	4/18/2013 69 views 4
	Total Elbow Arthoplasty in a Cadaver - Dr. Anthony Lauder and Dr. Thomas Trumble Sports - Surgical Techniques - Elbow Arthroplasty Performance of a total elbow arthroplasty in a cadaver	4/18/2013 51 views 4

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Groups

ABOS II: Elbow Arthroplasty

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7/29/2011

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Evidence & References Show References

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Yamaguchi K, Adams RA, Morrey BF. Infection after total elbow arthroplasty. J Bone Joint Surg Am. 1998 Apr;80(4):481-91 PMID:9563377 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Yamaguchi K, Morrey BF. Treatment of the infected total elbow arthroplasty. In: Morrey BF, ed. The Elbow and It's Disorders. 3rd ed. Philadelphia, PA: WB Saunders; 2000:678-684.

Undefined

Aldridge JM III, Lightdale NR, Mallon WJ, Coonrad RW. Total elbow arthroplasty with the Coonrad/ Coonrad-Morrey prosthesis. A 10- to 31-year survival analysis. J Bone Joint Surg Br. 2006 Apr;88(4):509- 14. PMID:16567787 (Link to Abstract)
Gill DR, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten to fifteen-year follow-up study. J Bone Joint Surg Am. 1998 Sep;80(9):1327-35. PMID:9759818 (Link to Abstract)

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