Updated: 10/15/2019

Elbow Partial Arthroplasty

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https://upload.orthobullets.com/topic/12111/images/arthroscopic olecranon fossa debridement_moved.jpg
https://upload.orthobullets.com/topic/12111/images/radial head excision_moved.jpg
  • 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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