total elbow arthroplasty

1. TOTAL ELBOW
ARTHROPLASTY
By –DR.ANIL KUMAR P
JUNIOR RESIDENT
DEPT OF ORTHOPAEDICS
RLJH, TAMAKA, KOLAR

2. INTRODUCTION
• Elbow arthroplasty involves the use of prostheses that replace
the normal surface anatomy of the distal humerus and proximal
ulna
• Total elbow arthroplasty is among the best studied procedures
in orthopedic surgery
• TEA for trauma is one of the fastest-growing indications

3. HISTORY
• The history of prosthetic replacement properly begins with
exoprosthetic replacement cairo toe dating back to 950 BC.
• The earliest attempts at elbow arthroplasty were resection
procedures performed as early as 1780.
• the earliest documentation of total endoprosthetic elbow
replacement was of an ivory device designed to treat elbow
resection for sarcoma in 1891 by Gluck.
• These designs were marginally successful in the short term and
ultimately failed because of instability or loosening due to poor
fixation and the lack of understanding of joint forces and
kinematics.

4. • These deficiencies were addressed in the late 1970s, resulting
in reliable elbow joint replacement, however, with continued
functional restrictions.
• Although we consider the “modern era” of joint replacement to
have begun in the 1970s with the introduction of poly methyl
methacrylate for fixation
•

5. INDICATIONS
• Rheumatoid arthritis (RA)
10-20% of patients with RA will have arthritic changes in the
elbow with radiological evidence of joint destruction not benefited
from radial head excision and synovectomy
Functional loss
Pain
Instability
• primary osteoarthritis (advanced)
• Failed elbow procedures

6. • Fracture
acute complex, unreconstructable intra-articular distal humerus
fracture
missed elbow fracture dislocation
• Post-traumatic osteoarthritis (advanced)
• chronic instability
• The best candidate for total elbow replacement has been
described as a patient with severely painful and disabling
rheumatoid arthritis with altered articular architecture

7. CONTRAINDICATIONS
• Active or recent elbow Sepsis(absolute)
• Poor soft tissue envelope
• Non restorable function of Biceps & Triceps
• Poor patient compliance with activity & weight lifting restrictions
• Flaccid paralysis of upper extremity
• Young vigorous patient with a post traumatic destroyed elbow

8. • Neuropathic elbow joint
• Ankylosis of ipsilateral shoulder
• Active patient younger than <65 years old
• Olecranon osteotomy
• Painless joint

9. GOAL OF TOTAL ELBOW
ARTHROPLASTY
• Restore functional mechanics of elbow
• Relief of pain
• Restoration of motion
• Stability

10. IMPLANT
• Selection of the type of prosthetic implant depends
1. on the state of the capsuloligamentous structures around the elbow
2. integrity of the musculature
3. amount of bone remaining at the elbow joint.
• More constrained prosthetic designs should be selected for patients
with injury to the stabilizing ligaments and capsule of the joint,
atrophic musculature, and loss of considerable bone stock

11. • Depending on rigidity of fixation of humeral component to ulnar
component
1.FULLY CONSTRAINED
2.SEMI CONSTRAINED
3.UNCONSTRAINED

12. FULLY CONSTRAINED
• Metal to metal hinge with PMMA cement fixation
Technical aspects
• Rigid hinged design
• They are designed with 7 degrees of rotary and side-to-side laxity
• Theoretically most stable design (versus unlinked)
Outcomes
• Highest loosening rates compared to semi constrained and
unconstrained designs
• Rarely used now as they have tendency to loosen & breakage
• Eg: stanmoore.Dee,Mckee.GSB1 & Mazas designs

14. SEMI CONSTRAINED
It’s a 2 or 3 part prosthesis
• Metal to high density polyethylene articulation connected with
locking pin or snap-fit device
• Have built in Valgus & varus laxity for side to side dissipation of
forces
• Technical aspects
• "sloppy hinge" allows for some varus-valgus and rotational
laxity
• reduces stress on bone-cement interface, which reduces
incidence of component loosening

15. • Outcomes
• 5- and 10-year survival rates have been reported at 93%
and 81%
• best results of all the designs
• complication of early humeral loosening with designs without
an anterior flange
• The best results from total elbow arthroplasty are obtained
when the procedure is done for rheumatoid arthritis, where
satisfactory results average about 90%
• Eg: Coonrad, Mayo

17. UNCONSTRAINED(surface replacement)
• 2 part prosthesis
• Metal to high density polyethylene articulation without locking
pin or snap-fit link
• Parts unlinked in a attempt to anatomically duplicates the
articular surface of the elbow
• Require normal intact ligaments, anterior capsule & appropriate
alignment

18. • 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
• 90% of patients may achieve satisfactory results when patient
selection and surgical techniques are satisfactory.
• aseptic loosening
• the survivorship was 96% and 84% at 5 and 10 years

20. PATIENT SELECTION
• End stage-Rheumatoid Arthritis with radiological evidence of joint
destruction.
• Acute unreconstructable fracture
• > 60 age
• Bilateral elbow ankylosis.
• Bony or fibrous ankylosis with elbow in poor functioning position
• As a revision of failed elbow arthroplasty
• Loss of bone stock caused by tumour/trauma
• End stage –Osteoarthritis
• Post traumatic arthritis
• Nonunion of distal humerus
• Hemophilic arthropathy

21. PRE-OP PLANNING
• Routine AP & lateral radiographs
• Assess humeral bow & medullary canal size in lateral projection
• size & angulation of the ulnar medullary canal In both projection
to be noted.
• Templates are available for all the varying size prostheses &
very useful
• Ulnar nerve examination-document if any degree of impairment
noted
• Elbow aspiration & culture to rule out joint sepsis

22. TECHNIQUE
• Place the patient supine with the
affected arm in front of the chest
and with a sandbag beneath the
ipsilateral shoulder
• Straight posteromedial incision
• Identify the ulnar nerve, gently
mobilize and protect it, and
transpose it anteriorly after the
operation

23. • Carefully elevate the triceps
mechanism in continuity with the
periosteum over the proximal
ulna and olecranon to avoid
transection or separation of the
triceps mechanism
• Reflect the triceps mechanism
to the radial side of the
olecranon to expose the
proximal ulna. Some prefer to
keep the triceps insertion intact
to avoid the risk of weakness
and rupture after surgery—the
so-called triceps-on approach.

24. • Release the collateral ligaments
on each side of the elbow
• Rotate the forearm laterally to
dislocate the elbow and allow
exposure of the distal humerus
• Remove the midportion of the
trochlea with an oscillating saw
to allow access to the medullary
canal of the humerus. Identify
the canal with a burr applied to
the roof of the olecranon fossa

25. • Preserve the medial and
lateral portions of the
supracondylar columns during
the preparation of the distal
humerus.
• Place the alignment stem
down the medullary canal
with a T-handle

26. • Apply the cutting block with
the appropriate right or left
placement of the side arm of
the cutting block.
• Use an oscillating saw to
remove the trochlear and
capitellar bone to correspond
with the size of the
appropriate cutting block

27. • Remove the bone carefully,
small amounts at a time,
repeatedly inserting the trial
prosthesis until the margins of
the prosthesis are exactly
level with the epicondylar
articular surface margins on
the capitellar and trochlear
sides

28. • Remove the tip of the
olecranon.
• Use a high-speed burr and
remove subchondral and
cancellous bone to allow
identification of the ulnar
medullary canal.
• Remove additional bone for
placement of the serial reamers
to be introduced down the
medullary canal of the ulna

29. • Select the appropriate size rasp
and use a burr to remove the
subchondral bone gently around
the coronoid process
• After the proximal ulna and
distal humerus have been
prepared, insert a trial
prosthesis and evaluate the
elbow for complete flexion and
extension , radial head
impingement on the
prosthesis(if so radial head
excision)

30. • place cement restrictors
• Use a cement gun
• Insert the ulnar component
first as far distally as the
coronoid process. Align the
center of the ulnar component
with the center of the greater
sigmoid notch

31. • Similar procedure for the
humerus component
• While the cement is still soft,
place the humeral component
down to a point that allows
articulation of the device and
the placement of the axis pin.
• Place the bone graft against
the distal humerus beneath
the soft tissue

32. • Articulate the humeral device
by placing the axis pin
through the humerus and
ulna. Secure it with a split
locking ring

33. • Place the arm in maximal
extension while the cement
hardens.
• Wound closed in layers .
(Triceps sutured back to
bone if released).

34. Play video

35. COMPLICATIONS
• Loosening (radiographic 17%, clinical 6%)most common mode of
failure for constrained
• Infection (8%)
• Instability
• Bushing wear
• Wound healing (higher with longterm steroid use)
• Ulnar neuropathy
• Triceps insufficiency
• Bone loss
• Periprosthetic fracture

36. COMPLICATIONS
RARELY REQUIRING SURGERY AVERAGE %
Nerve paresthesias 11
Wound problems 14
Fracture, humerus 5
Fracture, ulna 5
USUALLY REQUIRING SURGERY AVERAGE %
Nerve entrapment 3
Triceps problems 4
Ankylosis 4

37. USUALLY REQUIRING REVISION AVERAGE %
Loosening (semiconstrained) 5
Instability (unconstrained) 9
Infection 7
Fracture and loosening 5

38. • The unconstrained device had high rates of loosening (18%)
and instability (9%) that accounted for the inferior survival rate

39. Advantages
• Fixation is immediate and allows for early active motion after
wound healing.
• Patients obtain pain relief and recover motion sooner after TEA
when compared with other techniques
• Risk of developing painful post-traumatic arthritis does not exist.
• functional mechanics of elbow restored
• Relief of pain
• Range of motion at elbow joint
• Stability

40. POST OP CARE
• The extremity is elevated overnight with elbow above the shoulder.
• The drains & compressive dressing are removed the day after surgery.
• A light dressing is then applied & passive elbow flexion and extension are
allowed as tolerated. .
• Active elbow extension must be avoided for 3 months until the triceps
heals.
• Strengthening exercises are avoided.
• Patient is encouraged to avoid lifting more than 5 lb for the first 3 months
after surgery
• Thereafter, lifting is restricted to 10 pounds

41. DISADVANTAGES
• The biggest disadvantage after TEA is the lifetime 5-lb weight restriction
that stems from the significant forces placed across the implant–bone
interface with dynamic loading of the joint.
• Elderly patients frequently require assistive aids for ambulation; therefore,
they may not be compliant with their postoperative restrictions.
Other disadvantages of TEA include
• Implant loosening,
• Deep infection,
• Wound-healing problems,
• Periprosthetic fracture.
• There is a low revision rate within the first few years of surgery, but
concern for implant longevity exists.

42. RATING SYSTEM OF MORREY
• USED 3 CRITERIA TO RATE TEA
I. Xray appearance
II. pain
III. motion
1. GOOD RESULT: No radiographic change at the bone cement /prosthesis interface
No pain >90* of flexion 60* of pronation & supination
2. FAIR RESULTS : > 1mm of widening of any bone cement prosthesis interface •
Mild pain • Between 50* & 90* of flexion & extension • Less than 40* of
pronation & supination
3. POOR RESULTS : >2mm of widening of any bone cement prosthesis interface •
Pain that significantly limits activity • Less than 50* of flexion & extension •
Revision of elbow arthroplasty

43. Thanking you