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Updated: Sep 14 2023

Total Elbow Arthroplasty

Images
https://upload.orthobullets.com/topic/3089/images/semiconstrained tea.jpg
https://upload.orthobullets.com/topic/3089/images/15b_moved.jpg
https://upload.orthobullets.com/topic/3089/images/bf89806d-c410-40b7-96d2-6fa5b0d76a53_unconstrained.jpg
https://upload.orthobullets.com/topic/3089/images/6448f21b-37ea-4363-a463-481b5f4f8ec9_semiconstrained_1.jpg
https://upload.orthobullets.com/topic/3089/images/eb540329-3e6a-498d-bc4e-4af726bf72df_constrained_tea.jpg
https://upload.orthobullets.com/topic/3089/images/ularthr.jpg
  • 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
          • 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.
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