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Total elbow arthroplasty
TOTAL ELBOW ARTHROPLASTY JOHN
M. BEDNAR,
MD
Total elbow replacement arthroplasty is a technically demanding procedure that produces good results in those patients who meet the proper selection criteria. It allows improvement in the patient's quality of life by restoring pain-free function to the elbow. The result is greater function of the entire upper extremity by restoring the ability to place the hand where it is needed. This review will discuss the indications and contraindications to replacement arthroplasty. The surgical technique will be discussed highlighting important biomechanical factors that must be considered at the time of joint implantation. KEY WORDS: arthroplasty, elbow, joint replacement
Total elbow replacement was first reported in 1972 by Dee 1 using a hinged prosthesis in a patient with rheumatoid arthritis. This was followed by the use of several other kinds of metal-to-metal constrained prostheses that were held in place by methylmethacrylate cement. 2-4 The most common mode of failure in this patient population was loosening of the prosthesis due to the excess force placed on the bone-cement interface by the constrained prosthesis. The unacceptably high rate of loosening with constrained prosthesis has led to its abandonment. Unconstrained or minimally constrained designs were developed in response to this problem of loosening. The initial designs resurfaced the articular surfaces of the joint using components without stems. These early prostheses also loosened with a reported incidence of 70%5 until stems were added to prevent rocking of the components. Instability due to dislocation, subluxation, or maltracking of the prosthesis occurred in 5% to 20% of these patients, 5-9 especially those with preoperative bone loss in w h o m soft tissue balancing was difficult. This high incidence of instability in a technically difficult procedure led to further design modifications and the development of semiconstrained sloopy-hinged prostheses such as the MayoCoonrad (Zimmer, Warsaw, IN), triaxial, and Pritchard (Depuy, Warsaw, IN) designs, which have had excellent results in long-term studies. 1°-12
ment of the elbow (Fig 1). In this group of patients the entire upper extremity must be evaluated to determine the time of surgery. The return of function to the hand will best fulfill the primary goal of reconstruction, which is to improve function of the upper extremity. If the hand and wrist are limiting function, then they should first be addressed. If the hand and wrist are stable and functioning, attention may be given to the elbow and shoulder. If both are involved, the elbow should be the first joint to be reconstructed. 13 This greatly improves the function of the hand by allowing it to be placed where it is needed in space. If there is no shoulder rotation, the shoulder should be reconstructed first to prevent loosening of the elbow prosthesis due to the substantial varus, valgus, and rotatory stress placed on the elbow by an immobile shoulder. The indications for patients with posttraumatic arthritis are more limited. 14These patients should be treated conservatively or with nonimplant arthroplasty until such time that the joint surfaces are completely destroyed and motion is severely limited because of the pain. The age limit should be 60 years old. Patients younger than this have a much higher incidence of implant loosening and failure. A second group of patients for which replacement is indicated is the elderly group with a malunion (Fig 2) a n d / o r nonunion of a supracondylar or intercondylar fracture of the distal humerus, especially in those patients with poor bone stock.
INDICATIONS The primary indication for total elbow replacement arthroplasty is pain relief. A secondary indication is to provide stability, with restoration of motion a third indication but rarely the primary one. The largest group of patients that fit these indications are those with rheumatoid involve-
CONTRAINDICATIONS
From the Department of Orthopaedic Surgery, Jefferson Medical College of Thomas Jefferson University and The Philadelphia Hand Center, Philadelphia, PA. Address reprint requests to John M. Bednar, MD, Assistant Professor of Orthopaedic Surgery, Jefferson Medical College of Thomas Jefferson University and The Philadelphia Hand Center, 901 Walnut St, Philadelphia, PA 19107. Copyright © 1996 by W.B. Saunders Company 1048-6666/96/0602-0002505.00/0
The only absolute contraindication to total elbow arthroplasty is active infection in the form of septic arthritis or osteomyelitis. Other contraindications are relative and include the following: (1) age: patients younger than 60 years of age should be treated first with nonimplant procedures; (2) paralysis of the biceps and triceps: unless the function of these muscles can be restored by muscle or tendon transfer the arthroplasty will not function better than an arthrodesis; (3) soft tissue contracture: extensive soft tissue release will be required and special planning for bone resection is needed, with the goal of achieving a functional range of motion rather than full motion; and (4) arthrodesis: a stable painless arthrodesis should not be
64
Operative Techniques in Orthopaedics, Vol 6, No 2 (April), 1996: pp 64-68
Fig 1. (A and B) Rheumatoid involvement of the elbow.
converted to an arthroplasty unless bilateral involvement of the elbows is present.
SURGICAL APPROACH
Fig 2. Nonunited supracondylar fracture of the distal humerus.
TOTAL ELBOW ARTHROPLASTY
The Bryan approach 15 is preferred (Fig 3) for semiconstrained prosthesis implantation. This is performed through a longitudinal, posterior incision centered on the olecranon. The skin flaps are elevated at the fascia level and the ulnar nerve identified. The ulnar nerve is then released from the cubital tunnel, allowing for visualization throughout the entire procedure and anterior transposition at the time of closure. The medial aspect of the joint is identified and opened, releasing the medial collateral ligament. The triceps mechanism is elevated sharply from the proximal ulna and reflected in a lateral direction, with the extensor origin exposing the entire elbow joint. Bone cuts are then made according to the type of prosthesis to be implanted. Before cementing the ulnar component, holes should be drilled through the proximal ulna at the site of triceps attachment. Strong, nonabsorbable suture should be passed through these holes to allow reattachment of the triceps to the proximal ulna at the time of closure. This step will increase the resultant triceps strength and function. Minimally constrained prostheses depend on the medial collateral ligament and soft tissue balance for stability. If this type of prosthesis is to be implanted, the medial collateral ligament must either be preserved or reconstructed. The Kocher approach 16may alternatively be used for implantation of these prostheses. The Kocher approach is a posterolateral, longitudinal incision about the elbow.
65
Fig 3, Surgical approach for total elbow arthroplasty, (A) Bryan-Morrey posterior incision in which the ulnar nerve is identified and protected. (B) Triceps is released from the tip of the olecranon in continuity with forearm fascia and periosteum exposing area of bone to be resected (dotted lines), (C) Humeral and ulnar bone cuts completed. Triceps is reattached to the ulna,
The interval between the anconeus and the extensor carpi ulnaris is identified. The extensor mechanism from this interval is then elevated from lateral to medial, releasing the triceps from the olecranon. The medial collateral ligament is maintained and the joint opened based on the ligament to perform required bone resection and component insertion. This approach does not allow visualization of the ulnar nerve and therefore places the nerve at a higher risk for injury, either from direct contact or from stretching it unnecessarily. The center of rotation of the prosthesis must be placed at the normal center of rotation of the elbow. The ulnar component must be placed as far as possible posteriorly and distally. Anterior and proximal positioning of the implant will effectively lengthen the arm. This will place
66
excessive stretch and strain on the triceps mechanism and ulnar nerve. In addition, elbow flexion will be limited by the inability of the triceps to stretch.
RESULTS OF ARTHROPLASTY The overall success rate in most series of total elbow replacement arthroplasty is 90%. 11,16-20The patients with a semiconstrained prosthesis (Fig 4) predictably gain a greater range of motion than patients with the minimally constrained type, such as the capitellocondylar prosthesis. Pain relief is universally excellent. The rate of dislocation is 1% to 5% for the semiconstrained and 3% to 8% for the minimally constrained protheses. Loosening ranges from
JOHN M. BEDNAR
Fig 4. (A and B) Mayo Coonrad semiconstrained total elbow prosthesis. 1% to 3%. Infection is 1% to 3% a n d persistent u l n a r n e u r o p a t h y is less t h a n 2%.
SUMMARY Total e l b o w a r t h r o p l a s t y is a g o o d p r o c e d u r e for r e s t o r i n g f u n c t i o n to the e l b o w a n d u p p e r e x t r e m i t y in a p a t i e n t w i t h r h e u m a t o i d arthritis. Its use in patients w i t h t r a u m a t i c arthritis is e n c o u r a g e d in the o l d e r age g r o u p b u t n o t in y o u n g p a t i e n t s w h o will place h i g h stress o n the ,prosthesis. A d v a n c e s in i m p l a n t fixation to b o n e a n d better t r a n s m i s s i o n of l o a d f r o m i m p l a n t to b o n e will a l l o w its use in a y o u n g e r p a t i e n t p o p u l a t i o n w i t h p o s t t r a u m a t i c or d e g e n e r a t i v e arthritis.
REFERENCES 1. Dee R: Total replacement arthroplasty of the elbow for rheumatoid arthritis. J Bone Joint Surg Br 54B:88-95,1972 2. Bryan RS, Dobyns JH, Linscheid RL, et ah Preliminary experience 'with total elbow arthroplasty, in American Academy of Orthopaedic Surgeons Symposium on Osteoarthritis, St. Louis, MO, Mosby, 1976, pp 246-257
TOTAL ELBOW ARTHROPLASTY
3. Dee R: Total replacement of the elbow. Orthop Clin North Am 4:415-433, 1973 4. Garrett JC, Ewald FC, Thomas WH, et ah Loosening associated with G.S.B. hinge total elbow replacement in patients with rheumatoid arthritis. Clin Orthop 127:170-174,1977 5. Kudo H, Iwano K: Total elbow arthroplasty with a non-constrained surface replacement prosthesis in patients who have rheumatoid arthritis: A long-term follow-up study. J Bone Joint Surg Am 71A:10581065, 1990 6. Ewald FC, Simmons ED, Jr., Sullivan JA, et al: Capitel!ocondylar total elbow replacement in rheumatoid arthritis: Long term results. J Bone Joint Surg Am 75A:498-507,1993 7. Ruth JT, W~ldeAH: Capitellocondylar total elbow replacement. J Bone Joint Surg Am 74A:95-100,1992 8. Sourer WA: Arthroplasty of the elbow: with particular reference to metallic hinge arthroplasty in rheumatoid patients. Orthop Clin North Am 4:395-413, 1973 9. O'Driscoll SW: Elbow arthritis: Treatment options. J Am Acad Orthop Surg Vol 1(2):106-115, 1993 10. Morrey BF, Adams OPA: Semiconstrained arthroplasty for the treab ment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am 74A:479-490, 1992 11. Inglis AE, Pellicci PM: Total elbow replacement. J Bone Joint Surg Am 62A:1252-1258, 1980 12. Pritchard RW: Long4erm followup study: Semi-constrained elbow prosthesis. Orthopedics 4:151-155,1981
67
13. Friedman RJ, Ewald FC: Arthroplasty of the ipsilateral shoulder and
17. Inglis AE: Tri-Axial total elbow replacement: Indication, surgical
elbow in patients who have rheumatoid arthritis. J Bone Joint Surg Am 69A:661-667, 1987 14. Morrey BF, Adams RA, Bryan RS: Total replacement for posttraumatic arthritis of the elbow. J Bone Joint Surg Br 73B:607-612, 1991 15. Bryan RS, Morrey BF: Extensive posterior exposure of the elbow. Clin Orthop 166:188-192,1982 16. Ewald FC, Scheinberg RD, Poss R, et al: Capitellocondylar total elbow arthroplasty: Two to five year follow-up in rheumatoid arthritis. J Bone Joint Surg Am 62A:1259-1263, 1980
technique, and results, in Inglis AE (ed): Symposium on total joint replacement of the upper extremity. St. Louis, MO, Mosby, 1982, pp 100-110 18. Morrey BF, Bryan RS: Infection after total elbow arthroplasty. J Bone Joint Surg Am 65A:330-338, 1983 19. Morrey BF, Adams RA: Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am 74A:479-490, 1992 20. Goldberg VM, Figgie HE, III, Inglis AE, et al: Current concepts review: Total elbow arthroplasty. J Bone Joint Surg Am 70A:778-783, 1988
68
JOHN M. BEDNAR
M. BEDNAR,
MD
Total elbow replacement arthroplasty is a technically demanding procedure that produces good results in those patients who meet the proper selection criteria. It allows improvement in the patient's quality of life by restoring pain-free function to the elbow. The result is greater function of the entire upper extremity by restoring the ability to place the hand where it is needed. This review will discuss the indications and contraindications to replacement arthroplasty. The surgical technique will be discussed highlighting important biomechanical factors that must be considered at the time of joint implantation. KEY WORDS: arthroplasty, elbow, joint replacement
Total elbow replacement was first reported in 1972 by Dee 1 using a hinged prosthesis in a patient with rheumatoid arthritis. This was followed by the use of several other kinds of metal-to-metal constrained prostheses that were held in place by methylmethacrylate cement. 2-4 The most common mode of failure in this patient population was loosening of the prosthesis due to the excess force placed on the bone-cement interface by the constrained prosthesis. The unacceptably high rate of loosening with constrained prosthesis has led to its abandonment. Unconstrained or minimally constrained designs were developed in response to this problem of loosening. The initial designs resurfaced the articular surfaces of the joint using components without stems. These early prostheses also loosened with a reported incidence of 70%5 until stems were added to prevent rocking of the components. Instability due to dislocation, subluxation, or maltracking of the prosthesis occurred in 5% to 20% of these patients, 5-9 especially those with preoperative bone loss in w h o m soft tissue balancing was difficult. This high incidence of instability in a technically difficult procedure led to further design modifications and the development of semiconstrained sloopy-hinged prostheses such as the MayoCoonrad (Zimmer, Warsaw, IN), triaxial, and Pritchard (Depuy, Warsaw, IN) designs, which have had excellent results in long-term studies. 1°-12
ment of the elbow (Fig 1). In this group of patients the entire upper extremity must be evaluated to determine the time of surgery. The return of function to the hand will best fulfill the primary goal of reconstruction, which is to improve function of the upper extremity. If the hand and wrist are limiting function, then they should first be addressed. If the hand and wrist are stable and functioning, attention may be given to the elbow and shoulder. If both are involved, the elbow should be the first joint to be reconstructed. 13 This greatly improves the function of the hand by allowing it to be placed where it is needed in space. If there is no shoulder rotation, the shoulder should be reconstructed first to prevent loosening of the elbow prosthesis due to the substantial varus, valgus, and rotatory stress placed on the elbow by an immobile shoulder. The indications for patients with posttraumatic arthritis are more limited. 14These patients should be treated conservatively or with nonimplant arthroplasty until such time that the joint surfaces are completely destroyed and motion is severely limited because of the pain. The age limit should be 60 years old. Patients younger than this have a much higher incidence of implant loosening and failure. A second group of patients for which replacement is indicated is the elderly group with a malunion (Fig 2) a n d / o r nonunion of a supracondylar or intercondylar fracture of the distal humerus, especially in those patients with poor bone stock.
INDICATIONS The primary indication for total elbow replacement arthroplasty is pain relief. A secondary indication is to provide stability, with restoration of motion a third indication but rarely the primary one. The largest group of patients that fit these indications are those with rheumatoid involve-
CONTRAINDICATIONS
From the Department of Orthopaedic Surgery, Jefferson Medical College of Thomas Jefferson University and The Philadelphia Hand Center, Philadelphia, PA. Address reprint requests to John M. Bednar, MD, Assistant Professor of Orthopaedic Surgery, Jefferson Medical College of Thomas Jefferson University and The Philadelphia Hand Center, 901 Walnut St, Philadelphia, PA 19107. Copyright © 1996 by W.B. Saunders Company 1048-6666/96/0602-0002505.00/0
The only absolute contraindication to total elbow arthroplasty is active infection in the form of septic arthritis or osteomyelitis. Other contraindications are relative and include the following: (1) age: patients younger than 60 years of age should be treated first with nonimplant procedures; (2) paralysis of the biceps and triceps: unless the function of these muscles can be restored by muscle or tendon transfer the arthroplasty will not function better than an arthrodesis; (3) soft tissue contracture: extensive soft tissue release will be required and special planning for bone resection is needed, with the goal of achieving a functional range of motion rather than full motion; and (4) arthrodesis: a stable painless arthrodesis should not be
64
Operative Techniques in Orthopaedics, Vol 6, No 2 (April), 1996: pp 64-68
Fig 1. (A and B) Rheumatoid involvement of the elbow.
converted to an arthroplasty unless bilateral involvement of the elbows is present.
SURGICAL APPROACH
Fig 2. Nonunited supracondylar fracture of the distal humerus.
TOTAL ELBOW ARTHROPLASTY
The Bryan approach 15 is preferred (Fig 3) for semiconstrained prosthesis implantation. This is performed through a longitudinal, posterior incision centered on the olecranon. The skin flaps are elevated at the fascia level and the ulnar nerve identified. The ulnar nerve is then released from the cubital tunnel, allowing for visualization throughout the entire procedure and anterior transposition at the time of closure. The medial aspect of the joint is identified and opened, releasing the medial collateral ligament. The triceps mechanism is elevated sharply from the proximal ulna and reflected in a lateral direction, with the extensor origin exposing the entire elbow joint. Bone cuts are then made according to the type of prosthesis to be implanted. Before cementing the ulnar component, holes should be drilled through the proximal ulna at the site of triceps attachment. Strong, nonabsorbable suture should be passed through these holes to allow reattachment of the triceps to the proximal ulna at the time of closure. This step will increase the resultant triceps strength and function. Minimally constrained prostheses depend on the medial collateral ligament and soft tissue balance for stability. If this type of prosthesis is to be implanted, the medial collateral ligament must either be preserved or reconstructed. The Kocher approach 16may alternatively be used for implantation of these prostheses. The Kocher approach is a posterolateral, longitudinal incision about the elbow.
65
Fig 3, Surgical approach for total elbow arthroplasty, (A) Bryan-Morrey posterior incision in which the ulnar nerve is identified and protected. (B) Triceps is released from the tip of the olecranon in continuity with forearm fascia and periosteum exposing area of bone to be resected (dotted lines), (C) Humeral and ulnar bone cuts completed. Triceps is reattached to the ulna,
The interval between the anconeus and the extensor carpi ulnaris is identified. The extensor mechanism from this interval is then elevated from lateral to medial, releasing the triceps from the olecranon. The medial collateral ligament is maintained and the joint opened based on the ligament to perform required bone resection and component insertion. This approach does not allow visualization of the ulnar nerve and therefore places the nerve at a higher risk for injury, either from direct contact or from stretching it unnecessarily. The center of rotation of the prosthesis must be placed at the normal center of rotation of the elbow. The ulnar component must be placed as far as possible posteriorly and distally. Anterior and proximal positioning of the implant will effectively lengthen the arm. This will place
66
excessive stretch and strain on the triceps mechanism and ulnar nerve. In addition, elbow flexion will be limited by the inability of the triceps to stretch.
RESULTS OF ARTHROPLASTY The overall success rate in most series of total elbow replacement arthroplasty is 90%. 11,16-20The patients with a semiconstrained prosthesis (Fig 4) predictably gain a greater range of motion than patients with the minimally constrained type, such as the capitellocondylar prosthesis. Pain relief is universally excellent. The rate of dislocation is 1% to 5% for the semiconstrained and 3% to 8% for the minimally constrained protheses. Loosening ranges from
JOHN M. BEDNAR
Fig 4. (A and B) Mayo Coonrad semiconstrained total elbow prosthesis. 1% to 3%. Infection is 1% to 3% a n d persistent u l n a r n e u r o p a t h y is less t h a n 2%.
SUMMARY Total e l b o w a r t h r o p l a s t y is a g o o d p r o c e d u r e for r e s t o r i n g f u n c t i o n to the e l b o w a n d u p p e r e x t r e m i t y in a p a t i e n t w i t h r h e u m a t o i d arthritis. Its use in patients w i t h t r a u m a t i c arthritis is e n c o u r a g e d in the o l d e r age g r o u p b u t n o t in y o u n g p a t i e n t s w h o will place h i g h stress o n the ,prosthesis. A d v a n c e s in i m p l a n t fixation to b o n e a n d better t r a n s m i s s i o n of l o a d f r o m i m p l a n t to b o n e will a l l o w its use in a y o u n g e r p a t i e n t p o p u l a t i o n w i t h p o s t t r a u m a t i c or d e g e n e r a t i v e arthritis.
REFERENCES 1. Dee R: Total replacement arthroplasty of the elbow for rheumatoid arthritis. J Bone Joint Surg Br 54B:88-95,1972 2. Bryan RS, Dobyns JH, Linscheid RL, et ah Preliminary experience 'with total elbow arthroplasty, in American Academy of Orthopaedic Surgeons Symposium on Osteoarthritis, St. Louis, MO, Mosby, 1976, pp 246-257
TOTAL ELBOW ARTHROPLASTY
3. Dee R: Total replacement of the elbow. Orthop Clin North Am 4:415-433, 1973 4. Garrett JC, Ewald FC, Thomas WH, et ah Loosening associated with G.S.B. hinge total elbow replacement in patients with rheumatoid arthritis. Clin Orthop 127:170-174,1977 5. Kudo H, Iwano K: Total elbow arthroplasty with a non-constrained surface replacement prosthesis in patients who have rheumatoid arthritis: A long-term follow-up study. J Bone Joint Surg Am 71A:10581065, 1990 6. Ewald FC, Simmons ED, Jr., Sullivan JA, et al: Capitel!ocondylar total elbow replacement in rheumatoid arthritis: Long term results. J Bone Joint Surg Am 75A:498-507,1993 7. Ruth JT, W~ldeAH: Capitellocondylar total elbow replacement. J Bone Joint Surg Am 74A:95-100,1992 8. Sourer WA: Arthroplasty of the elbow: with particular reference to metallic hinge arthroplasty in rheumatoid patients. Orthop Clin North Am 4:395-413, 1973 9. O'Driscoll SW: Elbow arthritis: Treatment options. J Am Acad Orthop Surg Vol 1(2):106-115, 1993 10. Morrey BF, Adams OPA: Semiconstrained arthroplasty for the treab ment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am 74A:479-490, 1992 11. Inglis AE, Pellicci PM: Total elbow replacement. J Bone Joint Surg Am 62A:1252-1258, 1980 12. Pritchard RW: Long4erm followup study: Semi-constrained elbow prosthesis. Orthopedics 4:151-155,1981
67
13. Friedman RJ, Ewald FC: Arthroplasty of the ipsilateral shoulder and
17. Inglis AE: Tri-Axial total elbow replacement: Indication, surgical
elbow in patients who have rheumatoid arthritis. J Bone Joint Surg Am 69A:661-667, 1987 14. Morrey BF, Adams RA, Bryan RS: Total replacement for posttraumatic arthritis of the elbow. J Bone Joint Surg Br 73B:607-612, 1991 15. Bryan RS, Morrey BF: Extensive posterior exposure of the elbow. Clin Orthop 166:188-192,1982 16. Ewald FC, Scheinberg RD, Poss R, et al: Capitellocondylar total elbow arthroplasty: Two to five year follow-up in rheumatoid arthritis. J Bone Joint Surg Am 62A:1259-1263, 1980
technique, and results, in Inglis AE (ed): Symposium on total joint replacement of the upper extremity. St. Louis, MO, Mosby, 1982, pp 100-110 18. Morrey BF, Bryan RS: Infection after total elbow arthroplasty. J Bone Joint Surg Am 65A:330-338, 1983 19. Morrey BF, Adams RA: Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am 74A:479-490, 1992 20. Goldberg VM, Figgie HE, III, Inglis AE, et al: Current concepts review: Total elbow arthroplasty. J Bone Joint Surg Am 70A:778-783, 1988
68
JOHN M. BEDNAR