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