Arthroplasty

Indications

 

RA 

- very good results

- 97% 10 year survival Coonrad-Morrey prosthesis

 

Other Dx 

- OA / post-traumatic arthritis / nonunion

- tend to have worse survival than RA

 

Haemophilia

- elbow joint commonly involved

- 90% of haemophiliacs

 

Acute unreconstructable fracture > 60

 

Contra-indications

 

Sepsis

 

Poor soft tissue cover skin triceps

 

Under 60 years

 

Charcot Joint

 

Implant Types

 

1. Fully Constrained 

- have highest failure

 

2. Semi- constrained 

 

Coonrad-Morrey TER

- sloppy hinge

- allow some varus-valgus

 

3. Unconstrained 

 

Design

- stems on ulna & humerus to prevent loosening

- poly / metal bearing

- require MCL & LCL for stability

 

Technique Latitude Total Elbow Replacement

 

Total Elbow Latitude RATotal Elbow Latitude RA

 

Design

- can covert unlinked to linked simply at end of case or at later revision by adding anterior O piece

- unconstrained / semiconstrained

- anterior humeral flange with bone graft important for longetivity

 

Lateral position

- arm over bolster

 

Posterior Approach

- full thickness skin flaps

- identify and protect ulna nerve with vessiloops

 

Total Elbow Ulna Nerve

 

Triceps Options

 

A. Split in midline

- feathered off bone medially and laterally

- left attached distally

 

B.  Bryan-Morrey

- triceps elevated from subperiosteally

- from ulna to radial side

- periosteum left attached on radial side

 

C.  Triceps sparing

- elevate triceps tendon medially and laterally

- identify and protect ulna and radial nerve medially and laterally

- divide collaterals from humerus and dislocate elbow to medial aspect of triceps

 

Distal Humerus

- elevate and tag LCL / MCL for later repair

- elevate anterior capsule off humerus

 

Dislocate Elbow

 

Prepare humerus

 

1.  Size capitellum and trochlea with spool

- judge off distal humerus

- insert into olecranon and over radial head

 

2.  Stabilise centre of rotation

- most important

- centre of capitellum to medial epicondyle of trochlea (just distal and anterior to it)

- pass pin through

 

3.  Resect olecranon fossa, find entry to IM canal

- pass IM guide

 

4.  Attach resection jig to rotation and IM pins

5.  Drill holes made to establish area to resect with saw

6.  Need to leave medial column (some trochlea) and lateral column (some capitellum)

7.  Trial

 

Prepare ulna and radius

 

1.  Broach IM canal of ulna

2.  Pass IM jig, centre on ulna

- EM points towards ulna styloid

- fixed in position with 3 pins

3.  Use jig to 

- resect radial head

- burr prepares ulna lateral to medial

4.  Trial

 

Humeral / ulna and radius prosthesis inserted

- simplex cement

- cement restrictors

 

Closure

- collateral ligaments reattached through humeral prosthesis

- closure triceps over drain with Ethibond

 

Post op

- POP 1 - 2 weeks till wound healed

 

Results

 

Morrey et al JBJS Am 1998

- TER in rheumatoid arthritis

- followed for 10 years

- 92% survival rate

- 10% incidence of serious complication requiring re-operation

- infection / aseptic loosening / fracture / triceps avulsion / loosening

 

Morrey et al JBJS Am 2010

- TER in post traumatic arthritis

- 69 patients followed for 9 years

- 19% failure rate

- infection < 5 years, bushing failure 5-10 years, then component loosening

- most patients with failure < 60 years

 

Complications

 

Infection

 

Total Elbow Replacement InfectionTotal Elbow Joint Infected 2Infected TER

 

Incidence

- 4-5%

- most common cause of failure

 

Risk factors for infection

- previous surgery

- previous infection

- stage IV RA

- drainage post-op

- re-operation for any reason

- poor skin

 

Prevention

- Bier's block and IV antibiotics at beginning of case

- POP for 2 weeks post op to achieve wound healing

 

Management

 

Often follows superficial infection or bursitis

- need aggressive treatment of any superficial infection

- can often salvage joint with early debridement and washout

 

If signs of bony infection / loosening 

- 2 stage revision

- resection arthroplasty

 

Total Elbow Replacement Cement SpacerTotal Elbow Replacement Cement Spacer 2

 

Intraoperative fracture

 

Instability

 

More common in unconstrained

- 6%

 

Transient neuropraxia

- 5%

 

Triceps failure

- 2%

 

Loosening

 

Revision TER

 

Total elbow loose humeral component