- Discussion:
- upto 80 % of patients w/ traumatic DJD may expect a good to
excellent result at 5 years;
- upto 30 % of patients will sustain a major complication over 5
years, which in the majority of cases will require and additional operation;
- indications:
- end stage
rheumatoid
arthritis;
- severe intractable pain in
association with severe grade 3,4,5
- major cysts at
olecranon-coronoid junction, in association w/ severe grade 3-5 erosions;
- progressive loss of
extension beyond 60 deg;
- instability which indicates
very severe bone destruction and endangered ligamentous stability;
- fracture: comminuted
humeral intercondylar fracture in patients over age 70;
-
Distal humeral fractures treated with noncustom total elbow replacement. J
Bone Joint Surg Am 2004;86:940-947.
-
Distal humeral fractures treated with noncustom total elbow replacement.
Surgical technique.
- A comparison of ORIF and primary TEA in the treatment of intra-articular
distal humerus frx in women older than age 65. JOT 2003;17:473-480.
-
Primary total elbow replacement for fractures of the distal humerus.
- Preoperative considerations:
- if there is also significant RA involvement of the shoulder the
question is which joint should be adressed first;
- many authors will prefer to perform the total elbow arthroplasty
before the
TSR;
- allows greater amount of
time between arthroplasties and allows greater functional improvement;
- in addition w/ concomitant
disease in both joints, it can be difficult to judge humeral retroversion (due
to loss of ligamentous contrainsts in elbow;
- need for semiconstrained prosthesis:
- patients who have had previous radial head resection and
synovectomy (if unconstrained prosthesis is used);
- severe ligamentous laxity
(if unconstrained prosthesis is used);
- more than 2 cm of distal humeral bone loss (may require customized
prosthesis)
- references:
-
Total elbow arthroplasty after previous resection of the radial head and
synovectomy. J Bone Joint Surg Br 2005;87:47-53.
- Results of total elbow arthroplasty after excision of radial head and
synovectomy in patients who had RA. JBJS Am 1996;78:1541-1547
- Technique: (using the Coonrad-Morrey prosthesis -
semiconstrained); (Discovery™
Elbow System)
-
posterior triceps reflecting approach:
- tendon
splitting approach: tendon insertion to the proximal ulna
is elevated from the medial and lateral aspects of the ulna, keeping the
forearm fascia
extending to the proximal ulna intact;
- alternatively, medial half of
the triceps is reflected along with the posterior capsule, and the extensor
mechanism is reflected laterally;
-
ulnar nerve is
identified and is
transposed anteriorly;
- ligamentous
release:
- both collateral ligaments may be released off of epicondyles if a
semiconstrained prosthesis is used (such as semiconstrained modified
Coonrad-Morrey);
- anterior capsule release: anterior
capsule is released from the distal humerus to fully expose the joint and
release any contracture;
- tip of the olecranon (and
coronoid tip) is removed along w/ a portion of the MCL to gain better exposure;
- exposure is adequate when the
lateral column is exposed;
- references:
- The osteo-anconeus flap. An approach for total elbow arthroplasty.
- humeral preparation:
- if humerus is
prepared first then realize, then ulna is often smaller and may dictate sizing
options;
- only the diaphysis is needed
for secure fixation of the humeral component;
- deficiency or absence of an epicondyle should not be major problem;
- medullary canal is entered w/
a twist reamer and is exchanged for the alignment stem w/ the attached cutting
block (placed radially);
- cutting block: set to remove
an appropriate amount of distal humerus;
- consider seating the humeral
component more proximal than usual to help relax the anterior
soft-tissue envelope in extension
- ref:
Effect of humeral condylar resection on strength and functional outcome after
semiconstrained total elbow arthroplasty.
- controversies:
- cement vs press fit stems:
- in the report by H. Kudo et al (JBJS Vol 81-A. Sep 1999), the authors advocate
press fit fixation with a circumferential plasma spray
fixation of the humeral component;
- humeral fixation with a concomitant shoulder arthroplasty:
- in the report by Gill et al. (JBJS 81-A: 1128-1137);
- authors recommended filling IM canal with cement if the interval between the
humeral component stems is less than 6 cm);
- ulnar preparation:
-
olecranon tip is removed to gain straight-line access to the canal;
- medullary canal is entered w/
a high speed drill;
- the previously removed
olecranon tip facilitates entry into the canal;
- sequential rasping is
performed w/ care to avoid proximal ulnar complication;
- broach
parallel to the dorsal cortex to avoid malalignment;
- in the report by H. Kudo et
al (JBJS Vol 81-A. Sep 1999), the authors advocate use of an all polyethylene
cemented ulnar component;
- cement insertion:
- consider adding one gram of
tobramycin to the cement (see
addition of antibiotics to cement)
- use a cement gun to insert
cement;
- cement is allowed to harden
w/ the elbow in extension;
- component insertion:
- ulnar component is
articulated w/ the humeral component before the humeral component is seated;
- bone graft is placed behind
the anterior humeral component falange;
- this helps the humerus resist posterior displacement and rotational
displacement;
- remember that maximal stresses are found anteriorly at the insertion site of
the humeral component, and that after bone graft incorporates,
the thickened cortex will help resist these forces;
- humeral component is impacted
down the medullary canal;
- ulnar component is inserted;
- wound closure:
- triceps should be reattached
w/ intra-osseous sutures, which are inserted prior to component insertion;
- repair of the collateral
ligaments is not necessary;
- consider maintaining the
elbow in extension for 2-3 days inorder to allow the soft tissues to heal;
- Complications:
- posterior elbow dislocation;
- may occur in approximately 10% of patients undergoing unconstrained
arthroplasty;
- ulnar nerve dislocation;
- impingement of the radial head;
- proximal ulna fracture;
- hardware failure:
- worn bushings;
- fracture of ulnar component;
- infection:
- may range from 1 to 10%;
- in acute infection w/ non virulent organism (not staph epidermidis)
approximately 50% of patients may expect successful outcome from multiple
debridements and retention of components;
- as a requirement for this technique all bushing need to be
removed in order to allow a thorough washout;
- staged removal of components, debridements, and re-implantation of
components will be successful in the majority of patients if highly virulent
organisms are not present (such as stap epidermidis);
- staph epidermidis infections are expected to recur if components are
re-inserted;
- resection arthroplasty should result in the erradication of
infection and will provided relatively high rates of patient satisfaction
(despite poor function);
- references:
- Management of infection about total elbow prostheses.
- Infection after total elbow arthroplasty. K. Yamaguchi et al.
JBJS Vol 80-A. No 4. Apr 1988. p 481.
