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Total Elbow Arthroplasty
Steve Kronlage, MD
Total Elbow ArthroplastyIntroduction
• The elbow requires a stable, mobile joint to allow ADLs• 30-‐130º flexion/extension• 50-‐50º pronation/supination• Affected by RA, PTA, OA
Total Elbow Arthroplasty
• Removing and replacing a diseased elbow joint with metal and plastic• Not as durable as a hip, knee or shoulder arthroplasty• Multiple types have been tried
• Constrained• Unconstriained• Semiconstrained
• Semiconstrained has best track record
Elbow ArthroplastyGoals
• Pain Relief
• Restore motion
• Stability
Implant Type
• Constrained• Now off market• Simple hinge
• Unconstrained/Joint resurfacing• Semi-‐Constrained
Semi-‐constrained TEA
• “sloppy hinge”• Metal + high molecular weight
polyethylene• Articulation allows for
varus/valgus and rotational laxity
• Does not require collateral ligaments
• Can have poor bone stock
Biomet Discovery Technique
Joint Resurfacing “Unlinked”
• Theoretical lower wear rates
• Requires:• Bone stock• Collateral ligaments• Meticulous technique
• Not often done
Tornier
Semi-‐constrained vs Unlinked
• Designs are still evolving• Studies are difficult due to numbers and patient factors• Levy et al J Shoulder Elbow Surg 2009• 352 linked, 151 unlinked• 16% and 44% revision• 84% vs 56% long term survivorship • Linked does better *in this study
Indications
• End stage arthritis• Old• RA (can be younger)• Post-‐traumatic OA• Acute distal humeral fracture > 65• Tumor, hemophilia, distal humeral nonunion
Contraindications
• Acute or recent infection• Poor soft tissue• Non-‐functioning triceps (relative)• Non-‐compliance with weight restrictions• Young• Neuropathic Joint
Preoperative Assessment
• Imagining, Plain films and CT• Medical assessment• Nutritional eval• Soft tissue envelope
Surgical TechniqueTriceps
• Triceps has to be mobilized to get to the joint
• Triceps has to be “reflected if resurfacing”
• Triceps can be spared if ligaments removed
• Triceps insufficiency is a significant complication
Sanchez-Sotolo, Morrey, J Am Acad Orthop Surg2011;19:121-125
Choo & Ramsey:J Am Acad Orthop Surg2013;21:427-437
TechniqueUlna
• EXPOSURE• Difficult to ream and broach due
to anatomy• Most often takes a ‘free hand
technique’• Ulna is bowed• Cement is necessary
Ulna Continued
• Have to reattach triceps if off—need bone
• Previous or current olecranon fracture is a difficult problem
• Can treat with fixation
Humerus
• Try to replicate the epicondyle axis
• Rotation will be set with anterior flange
• Cement technique not like a hip, different bone
Articulation
• Biomet uses hemispherical articulations with polyethylene in the ulnar component
• Zimmer uses a pin and poly• Both difficult with the triceps
attached
Post-‐operative treatment TEA
• Drain• Immobilization• Triceps sparing 2 weeks• Triceps repair/reflecting: 4 weeks
• Therapy based on preoperative ADL and triceps status• WEIGHT RESTRICTIONS
OutcomesTEA
• Predictable• Pain relief• Functional improvement
• Different outcomes based on preoperative state• RA• PTA• OA• Fractures
Outcome TEARheumatoid Arthritis
• Gill and Morrey 1999 JBJS• 10-‐15 year follow up pain relief and increase function• 92.4% survivorship free of revision at 10-‐12 years• Complications (14%)• Infection• Triceps avulsion• Periprosthetic fracture• Loosening of components
Post-‐traumatic Arthritisoutcomes
• Increasingly used as adjuvant to care• High complication rate (27-‐43%) and reoperation rate (22-‐
28%) Choo & Ramsey:J Am Acad Orthop Surg 2013;21:427-437
• Higher failure rates seen in those <60 years old
Outcome TEA Distal Humeral Fracture
• Manages acute injury rather that the late presentation of disease or injury
• McKee et al J Shoulder Elbow Surg 2009:• Prospective randomized study comparing ORIF with TEA• Faster, better outcomes, better ROM and fewer reoperations
• Distal Humeral Replacement alone?
TEA for Distal Humeral Fractures10-‐year follow up JBJS 99:18 (2017)
• 44 patients• Great results with motion and pain (23º-‐123º, vas 0.6)• 11% deep infection• 18% revision or resection• 11% periprosthetic fractures• Males with more revisions/problems•*Not insignificant complications
Complications
• Can be devastating• Infection• Aseptic loosening• Implant failure from poly wear• Periprosthetic fracture• Triceps insufficiency• Wound complications• Ulnar nerve issues
Complication Rate
• Krenek, et al. J Hand Surg Am 2011 Jan;36(1) 68-‐73
• Looked at the state of CA discharge database• 1995-‐2005• 1625 patients with TEA• 170 had early complications/132 had reoperation• 10% complication rate• 8% reoperation rate in first 90 days
Infection
• The most devastating complication• Ranges from 3-‐11%• Prevention is best cure• IF caught early may manage with
irrigation and debridement with retention of components
• Otherwise will need staged resection and implantation
Loosening
• Cement bone interface most common• Especially osteoporotic bone• Much higher in linked• Can lead to periprosthetic fracture• New designs are using no cement
• Canada only right now
Component failure
• Polyethylene bearings can wear.• Newer components have changed
from the pin to a spherical type articulation.
• Wright and Hastings J Shouder and Elbow Surg 2005• Found 10 patients needing revision due to
bushing wear at 10 years• High use was found to be contributory
• Theoretically less wear
Periprosthetic Fractures
• Usually occur around a stem that is loose
• If loose and fractured, it must be revised
• If it is a fracture with a fixed stem, then the bone can be stabilized
Triceps Insufficiency
• Common in rheumatoid arthritis• Use of a triceps sparing approach is used if possible• Triceps insufficiency does not have to be fixed, gravity will
extend• Grafts are used to reconstruct the extensor mechanism if
symptomatic
Ulnar Nerve
• Common due to location, previous trauma and disease• Thought to be lower when transposed at the time of surgery• Can be related to traction or thermal injuries during
procedure• 40% of patients have paresthesia in the ulnar nerve
distribution in first 2 weeks • May require a revision procedure if unresolved
Young Patients
• Celli, Morrey JBJS 2009, Jun: 91(6);1414-‐8:
• TEA in those 40 years old or younger• 55 TEA in 49 patients• At least 5 year follow up• Inflammatory arthritis 30, PTA 19• 6 bilateral, mean f/u 91 months• 12 (22%) had subsequent procedure
• 4 loose, 3 triceps weakness, 3 wear, 2 deep infection
• Revision rate significantly higher for PTA
Young Patients
• Schoch, et al J Hand Surg Am. 2017
• 11 patients under 50 with a linked TEA• 82% complication rate• 6 mechanical failures (loosening)• Surviving implants 2 excellent, 1 good, 2 fair
•*significant mechanical loosening in younger patients
Obesity
• Griffin et al J Shoulder Elbow 2015 Oct;24(10):1594-‐6• 2005-‐2011, 7580 patients underwent TEA in the US• 1030 (14%) obese with BMI > 30• 611 (8%) morbidly obese BMI > 40• Increase in VTE, infections, medical complications, • Increase in implant removal at 6 months and one year in morbidly obese
Bone Loss
• Bone loss can be common after revision TEA
• Ulnar and humeral components have unique problems
• Can be treated with custom made implants and/or allograft replacement
Bone Loss
Total Elbow ArthroplastySummary
• Effective for pain relief in selected patients• Complications can be significant• Technically demanding• There will likely be more implanted due to aging population • Lots of room for improvement
Thank You
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