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Total Elbow Arthroplasty
PROCEDURE 49
Total Elbow Arthroplasty Steven M. Koehler and David S. Ruch INDICATIONS • Diffuse inflammatory arthropathy of the elbow • Diffuse severe osteoarthritis of the elbow in the elderly • Low, comminuted distal humerus fractures in elderly, low-demand patients • Chromic, unreconstructable instability of the elbow • Segmental bone loss of the elbow from tumor or trauma • Elbow intraarticular or extraarticular nonunions • Patient willingness to accept lifelong activity restrictions
INDICATIONS PITFALLS
• Presence of infection • Noncompliant patient who will not restrict or limit lifting or repetitive sports • Lack of a healthy soft tissue envelope • Complete and painless ankylosis of a neuropathic elbow joint • Skeletally immature patients
EXAMINATION/IMAGING • Anteroposterior (AP) radiograph (Fig. 49.1A) • Lateral radiograph (see Fig. 49.1B)
A
C
B
D FIG. 49.1 A–D
475
476
PROCEDURE 49 Total Elbow Arthroplasty
INDICATIONS CONTROVERSIES
• Arthroplasty for nonrheumatoid patients with distal humerus fractures • Arthroplasty in patients younger than 60 years of age • Arthroplasty in osteoarthritis • Conversion of an elbow arthrodesis to a total elbow arthroplasty for functional improvement • Linked versus unlinked implants. We recommend that the choice of implant be made based on the surgeon’s preference and familiarity with the implant and the patients’ disease state and particularities.
POSITIONING PEARLS
• Carefully protect bony prominences with pillows between the legs, pillows under the proximal fibula, and foam under the nonoperative elbow. • Axillary roll should be used in the lateral decubitus position.
POSITIONING EQUIPMENT
• Suction beanbag • Pillows and foam padding • Radiolucent arm positioner • Use of a sterile tourniquet • High-speed burr • Drill and bits of various size • Oscillating saw • Pulse lavage • Curettes • Appropriately sized humeral and ulnar canal cement restrictors • Pressurized cement gun with appropriate sized nozzle or 60-mL syringe with 10-g 3-inch angiocath • Antibiotic impregnated cement (we routinely use) • Fluoroscopy • Nerve stimulator—this can be helpful in identifying the ulnar nerve in cases of prior trauma or prior transposition
POSITIONING CONTROVERSIES
• Lateral decubitus position • Supine position
PORTALS/EXPOSURES PEARLS
• We use the Bryan-Morrey triceps reflection exposure. • We routinely release the collateral ligaments to increase joint exposure. This is mandatory when operating on a stiff or contracted elbow. PORTALS/EXPOSURES PITFALLS
• Olecranon osteotomy must be avoided. • Inappropriate cleaning of bone debris can predispose the formation of heterotopic bone.
• A radiocapitellar (Coyle) view if necessary (see Fig. 49.1C) • Wrist posteroanterior and lateral radiographs if forearm rotation is deficient and the distal radioulnar joint requires evaluation • Although we do not typically obtain computed tomography (CT) scanning and magnetic resonance imaging (MRI), CT scans with three-dimensional reconstructions can be particularly helpful in complex cases, especially those following trauma. • Wrist radiographs if forearm rotation is deficient and the distal radioulnar joint requires evaluation (see Fig. 49.1D)
SURGICAL ANATOMY • The elbow is a “tie arch” formed by the medial and lateral condyles that contain the articular surfaces. The medial epicondyle serves as an attachment point for the medial ulnar collateral ligament and the flexor-pronator muscle group. The lateral epicondyle is the origin of the lateral ulnar collateral ligament and the extensorsupinator muscle group. • The proximal ulna contains the incisura semilunaris, which is the major articulation of the elbow and is responsible for its inherent stability. Medially, the sublime tubercle is the insertion of the medial ulnar collateral ligament. Laterally, the supinator tuberosity is the insertion of the lateral ulnar collateral ligament. • The elbow joint is classified as a trochoginglymoid joint. The ulnohumeral joint allows flexion and extension, whereas the radiohumeral and proximal radioulnar joints allow for axial rotation. • In the lateral plane, the orientation of the articular surface of the distal humerus is rotated anteriorly 30 degrees with respect to the long axis of the humerus. • The center of the concentric arc formed by the trochlea and capitellum is on a line coplanar to the anterior distal cortex of the humerus. • In the axial plane the articular surface and the axis of rotation is internally rotated 5–7 degrees. • In the coronal plane the articular surface is in 6–8 degrees of valgus. • The carrying angle is the angle formed by the long axis of the humerus and the ulna when the elbow is fully extended. In men the average angle is 11–14 degrees, and in women it is 13–16 degrees. • The median nerve crosses anterior to the brachial artery as it passes across the intermuscular septum. It then follows a direct course into the antecubital fossa, medial to the biceps tendon and the brachial artery. The first motor branch is in the forearm to the pronator teres, through which it passes. • The radial nerve enters the anterior aspect of the arm as it penetrates the lateral intermuscular septum after giving off motor branches to the triceps. At this point, and onward, the nerve becomes at risk for injury during elbow surgery. After penetration of the septum, it descends anterior to the lateral epicondyle, innervating the brachioradialis. In the antecubital space the nerve divides into a superficial branch and deep branch. The deep branch is recurrent, passing deep to the supinator (innervating it). As it courses through the supinator muscle, the nerve lies over a bare area of the radius opposite to the radial tuberosity. Here it is at risk for injury. After emergence from the supinator, the nerve becomes the posterior interosseous nerve. • At the elbow, the ulnar nerve passes into the cubital tunnel under the medial epicondyle and lies against the medial collateral ligament.
POSITIONING • We routinely position patients in the lateral decubitus position (Fig. 49.2). • We routinely use a radiolucent arm positioner to drape the arm over, acting as a stabilizer for the surgery.
PROCEDURE 49 Total Elbow Arthroplasty
477
PORTALS/EXPOSURES CONTROVERSIES
• The management of the extensor mechanism varies by surgeon preference. • Triceps-on, while reducing the risk of triceps insufficiency, does compromise visualization to some extent. • Regardless of exposure choice, visualization of the joint, the proximal ulna, and the distal humeral shaft must be present. • Whether and how to address the ulnar nerve continues to brew controversy. Articles have been published arguing in favor of routine transposition or in situ–only decompression. However, most authors agree that the ulnar nerve should be considered and addressed in some form or fashion. We routinely transpose it subcutaneously.
FIG. 49.2
STEP 1 PEARLS
A
B
C FIG. 49.3 A–C
PROCEDURE
• For skin preparation we prefer chlorhexidinealcohol. • We routinely perform preoperative methicillinresistant Staphylococcus aureus (MRSA) surveillance and pretreat MRSA-carrying patients with 5 days of nasal mupirocin ointment and chlorhexidine baths. • MRSA-carrying patients will receive vancomycin perioperative antibiotics per Surgical Care Improvement (SCIP) guidelines. • We typically use Ioban draping, although care with the incision must be taken because it is not uncommon for the skin to shift excessively to unintended positions. • We incorporate previous incisions where possible.
Step 1: Setup • Regional anesthesia with sedation is used. • A sterile tourniquet is used and set to 75 mm Hg greater than the systolic pressure (see Fig. 49.2).
Step 2: Exposure • Skin is incised down to fascia. Full-thickness flaps are elevated medially and laterally to expose the ulnar nerve and the triceps expansion (Fig. 49.3A). • The ulnar nerve is identified proximal to Osborne ligament, and decompression proceeds from proximal to distal (see Fig. 49.3B and C). • If the nerve is to be transposed (as is routine), the arcade of Struthers must be released and the intermuscular septum must be excised.
STEP 2 PEARLS
• Deformity may alter ulnar nerve position at the elbow. • Careful preoperative examination of the ulnar nerve pathology is mandatory.
STEP 2 PITFALLS
• Maintain the epineural vasculature to the ulnar nerve during transposition. • Avoid the use of a Penrose drain or other fixed retractors on the ulnar nerve.
Step 3: Triceps Elevation • Over the medial aspect of the proximal ulna, the ulnar periosteum is elevated along with forearm fascia (Fig. 49.4A). • The triceps is elevated from the proximal ulna by transecting Sharpey fibers at the site of insertion (see Fig. 49.4B).
STEP 2 CONTROVERSIES
• The skin incision can be straight or curved, depending on the surgeon’s preference.
A
B
C FIG. 49.4 A–C
FIG. 49.5
A B
Excise Triceps attachment
FIG. 49.6 A–B
PROCEDURE 49 Total Elbow Arthroplasty
A
B
C
479
D
FIG. 49.7
STEP 3 PEARLS
• In rheumatoid patients, we release the medial and lateral collateral ligament complexes from their attachments when implanting a semiconstrained, linked prosthesis. The release of collateral ligaments will depend on the prosthesis the surgeon has selected.
A
B FIG. 49.8
• The extensor mechanism, including the anconeus, is reflected laterally to allow complete exposure (see Fig. 49.4C). • The tip of the olecranon is removed (Figs. 49.5 and 49.6).
Step 4: Humeral Preparation • To ensure there is adequate room for instrumentation and the anterior flange, release the anterior capsule from the distal humerus and elevate the brachialis muscle with a broad periosteal elevator (Fig. 49.7). • The midportion of the trochlea is removed with a rongeur or a saw (Fig. 49.8). • The medullary canal is found at the roof of the olecranon fossa and entered with a burr (Fig. 49.9A). • Next, after a pilot hole has been established, the medullary canal is entered with a twist reamer (see Fig. 49.9B). • The medial and lateral aspects of the supracondylar columns should be identified and visualized throughout humeral preparation to ensure proper orientation and alignment. • The alignment stem is placed down the canal, the handle is removed, and the cutting block is attached. Accurate resection of the distal humerus is now possible (Fig. 49.10A). • The side arm of the cutting block is attached to the lateral aspect of the cutting block to the rest on the capitellum and provides the appropriate depth of cut (see Fig. 49.10B). • Using an oscillating saw, the trochlea is removed via the cutting block (see Fig. 49.10C and D).
STEP 3 PITFALLS
• Poor exposure of the joint, proximal ulna and distal humeral shafts may result in inadvertent supracondylar column fracture or cortical perforation.
STEP 4 PEARLS
• Use the most reliable landmark to define the flexion axis. We prefer the anterior cortex to establish the anterior/posterior position, the roof of the coronoid fossa to gauge depth, and the plane of the columns to define the humeral component axis of rotation. • The flat part of the cutting guide should rest on the posterior columns to ensure rotatory alignment of the humeral implant. • Use a burr in a younger patient, especially with posttraumatic conditions, to remove the hard bone just proximal to the olecranon fossa.
STEP 4 PITFALLS
• Violation of either supracondylar bony column when resecting the trochlea can lead to stress risers resulting in supracondylar fracture and subsequent implant failure. The importance of saw control cannot be overemphasized. At times, it may be easier to start or complete cuts with a pencil-tipped burr.
480
PROCEDURE 49 Total Elbow Arthroplasty
A
B FIG. 49.9 A–B
A
B
C
D
FIG. 49.10 A–D
STEP 5 PEARLS
• The ulnar medullary canal is identified using a high-speed burr at a 45-degree angle to the base of the coronoid. • Implant rotation is determined by placing the flexion plane perpendicular to the “flat” portion of the proximal ulnar rasp. • If implanting an extra-small ulnar component, the starter rasp should be the final rasp. It should be fully seated to fit the extra-small implant.
FIG. 49.11
Step 5: Ulnar Preparation • Present the ulna and the incisura semilunaris (Fig. 49.11). • If not done already, remove the tip of the olecranon to allow access to the canal. • Identify the medullary canal of the ulna. We use a high-speed burr to open the canal and then enlarge the opening with a combination of the burr, ulnar rasps, and, when indicated, ulnar broaches. • Remove the subchondral bone around the coronoid. • Prepare the proximal canal by using a rasp (Fig. 49.12).
PROCEDURE 49 Total Elbow Arthroplasty
A
B FIG. 49.12
A
B FIG. 49.13
FIG. 49.14
Step 6: Implantation • The first step to a successful implantation is trial reduction. Trial reduction allows assessment of depth insertion and soft tissue restrictions to motion. If the elbow does not fully extend, do not force it into extension. This may drive the humeral implant into the humerus, fracturing the condyles (Fig. 49.13). • During trial reduction, we measure and precut the bone graft for the anterior flange. We use bone graft from the excised trochlea, when possible, or allograft to place anteriorly. Usually the graft measures 2–3 mm thick, 1.5 cm long, and 1 cm wide. • The medullary canals of both the humerus and the ulna should be cleaned and dried. • A medullary cement restrictor should be placed in the humerus (Fig. 49.14). • On the back table, we couple the ulnar and humeral components. They are articulated and connected with the outer, hollow axis pin and the internal, solid pin (Fig. 49.15A and B).
FIG. 49.15 A–B
481
482
PROCEDURE 49 Total Elbow Arthroplasty
FIG. 49.16
FIG. 49.17
STEP 6 PEARLS
• The ulna should be inserted until the center of the ulnar component coincides with the center of the greater sigmoid fossa. • Attention should be given to proper bone grafting anteriorly beneath the anterior flange. This increases the bone stock at the point of maximum stress and helps resist torsional forces associated with loosening. Remember, sometimes bone grafting is unnecessary and doing so will anteriorize the humeral component, preventing complete seating of the component and restoration of the axis of rotation. • When the radial head is degenerative or deformed, the radial head is exposed and excised via a cut made through the neck, just distal to the head. Care must be taken to protect the posterior interosseous nerve. • Take care to remove any excess cement. STEP 6 PITFALLS
• Poor cementing technique
STEP 6 CONTROVERSIES
• Management of the radial head is a topic of continued debate. Some prostheses, such as the Latitude, incorporate radial head arthroplasty. However, this is not the case in most prostheses that are linked. As for unlinked prostheses, the radial head component is hypothesized to decrease the stress on the ulnohumeral articulation, reducing wear, osteolysis, and loosening. In linked implants, the radial head is not necessary for stability. The Coonrad-Morrey prosthesis allows for the presence or resection of the radial head. We believe that management of the radial head should be based on the patient’s disease state. In rheumatoids, the proximal radioulnar joint is often a site of painful synovitis, and resection is necessary. In patients with posttraumatic arthritis or acute fractures, the radial head may be normal and it can be preserved.
FIG. 49.18
• We recommend injection technique for insertion of the cement to ensure a proper mantle. We generally use a 60-mL syringe filled with cement to inject the canals of both the humerus and ulna (Fig. 49.16). • Prior to the cement drying, the ulnar and humeral components are inserted as an articulated unit (Fig. 49.17). • The humerus is positioned down the medullary canal to where the base of the flange is flush with the anterior portion of the coronoid fossa, thus restoring the anatomic axis of rotation. • After the humeral component is inserted into the cement, we place the graft between the anterior cortex and the flange. It is impacted with a bone tamp prior to cement setting. • The elbow is positioned in full extension to fully seat the implants (Fig. 49.18).
Step 7: Triceps Management • We follow the technique well described by Morrey in our repair of the triceps. • We make three drill holes in the ulna: a cruciate and a transverse. • The no. 5 suture is placed onto a Keith needle and passed through one of the cruciate holes. It is then weaved in a Krackow fashion proximally and then distally in the triceps tendon. We pass it back through the other cruciate hole and then through the soft tissue of the distal triceps insertion. Next, it is passed through the transverse hole, and the suture is then tied to itself.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Early satisfaction and pain relief from semiconstrained total elbow arthroplasty (TEA) approaches 90% in most series. • Prosthesis survival at 10 years is 92%, with 86% having good or excellent results in inflammatory arthropathies. • Mean Mayo Elbow Performance Score for follow-up at 10–31 years was 91 in inflammatory arthropathies. • Prosthesis survival at 15 years is 70% in posttraumatic arthritis.
PROCEDURE 49 Total Elbow Arthroplasty
• Infection after TEA occurs in approximately 5% (reported up to 12%) and is strongly associated with postoperative drainage; 20% of patients with postoperative drainage develop an infection. Drainage for more than 10 days postoperatively is very strongly correlated with infection.
EVIDENCE Gill DR, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten- to fifteen-year follow-up study. J Bone Joint Surg Am 1998;80:1327–35. In this 1998 study the authors reported 10- to 15- year follow-up of the Coonrad-Morrey TEA for patients with rheumatoid arthritis from the Mayo Clinic. Mean arc of flexion/extension was 28/131 degrees and pronation/supination 68/62 degrees; 97% of patients had pain relief. The complication rate was 14%, and the overall survival of the prosthesis was 92%. There was an 86% satisfaction rate on the Mayo Elbow Performance Score (MEPS). Kraay MJ, Figgie MP, Inglis AE, et al. Primary semiconstrained total elbow arthroplasty. Survival analysis of 113 consecutive cases. J Bone Joint Surg Br 1994;76:636–40. In this 1994 study the authors reviewed the survival of TEAs in 113 elbows at 3–5-year follow-up. Survival was 92% in inflammatory arthritis. Little CP, Graham AJ, Carr AJ. Total elbow arthroplasty: a systemic review of the literature in the English language until the end of 2003. J Bone Joint Surg Br 2005;87:437–44. In this systemic review, 86 papers reporting the outcomes of 3618 implanted TEAs, with an average of 60-month follow-up, were reviewed. The overall revision rate was 13%. Good to excellent function was reported in 78% of patients. In rheumatoid arthritis, 1093 elbows were reviewed, with a reported revision rate of 10% at 58 months, loosening rate of 12%, and 83% reporting goodexcellent function. In posttraumatic arthritis, 120 elbows were reviewed, with a revision rate of 10% at 99 months, loosening rate of 3%, and 81% reporting good-excellent function. In acute fractures, 79 elbows were reviewed, with a reported revision rate of 3% at 36 months, loosening rate of 0%, and 99% reporting good-excellent function. Sanchez-Sotelo J, Baghdadi YM, Morrey BF. Primary linked semiconstrained total elbow arthroplasty for rheumatoid arthritis: a single-institution experience with 461 elbows over three decades. J Bone Joint Surg Am 2016;98:1741–8. This study reported the outcomes of elbows with a minimum of 2-year follow-up, average of 10year follow-up, and maximum of 30-year follow-up; 11% of elbows required component revision or removal, mostly for mechanical failure. The median MEPS was 90. The rate of survivorship free of implant revision or removal was 92% at 10 years, 83% at 15 years, and 68% at 20 years. Throckmorton T, Zarkadas P, Sanchez-Sotelo J, et al. Failure patterns after linked semiconstrained total elbow arthroplasty for posttraumatic arthritis. J Bone Joint Surg Am 2010;92:1432–41. Eighty-five semiconstrained TEAs were reviewed for posttraumatic arthritis; 68% achieved a good or excellent clinical result, and 74% of patients were satisfied. The 15-year revision-free survival rate was 70%, and 75% of all failures occurred in patients less than 60 years of age.
483
STEP 7 PEARLS
• The triceps must be restored to its anatomic position and well secured to ensure a good outcome. • No. 5 nonabsorbable suture is used. • We routinely use a drain to prevent hematoma formation. POSTOPERATIVE PEARLS
• Immobilize in 40 degrees of extension with an anterior plaster shell splint for 24–48 hours with the elbow elevated above the shoulder. • We remove the drain after 24 hours. • We then replace the plaster splint with a bulky dressing to limit postoperative edema but allow for flexion and extension. • At 7 days, normal light use of the elbow for the activities of daily living is permitted. • Sutures or staples are removed at 14 days. • No formal physical therapy is required or indicated. Due to weight-lifting restrictions, strengthening is discouraged. • Patients should avoid lifting with the surgical extremity more than 1 kg on a repetitive basis or more than 4.5 kg on a single event. • If postoperative wound drainage does not resolve within 5 days, we recommend a formal operative debridement, culture, and revision closure of the arthroplasty. • Asymptomatic radiographic lucencies should be observed for progression, but they do not imply implant loosening. • Significant heterotopic ossification is uncommon after arthroplasty. POSTOPERATIVE PITFALLS
• Infection • Ulnar neuropathy • Extensor mechanism failure • Instability • Periprosthetic fractures • Aseptic loosening
Total Elbow Arthroplasty Steven M. Koehler and David S. Ruch INDICATIONS • Diffuse inflammatory arthropathy of the elbow • Diffuse severe osteoarthritis of the elbow in the elderly • Low, comminuted distal humerus fractures in elderly, low-demand patients • Chromic, unreconstructable instability of the elbow • Segmental bone loss of the elbow from tumor or trauma • Elbow intraarticular or extraarticular nonunions • Patient willingness to accept lifelong activity restrictions
INDICATIONS PITFALLS
• Presence of infection • Noncompliant patient who will not restrict or limit lifting or repetitive sports • Lack of a healthy soft tissue envelope • Complete and painless ankylosis of a neuropathic elbow joint • Skeletally immature patients
EXAMINATION/IMAGING • Anteroposterior (AP) radiograph (Fig. 49.1A) • Lateral radiograph (see Fig. 49.1B)
A
C
B
D FIG. 49.1 A–D
475
476
PROCEDURE 49 Total Elbow Arthroplasty
INDICATIONS CONTROVERSIES
• Arthroplasty for nonrheumatoid patients with distal humerus fractures • Arthroplasty in patients younger than 60 years of age • Arthroplasty in osteoarthritis • Conversion of an elbow arthrodesis to a total elbow arthroplasty for functional improvement • Linked versus unlinked implants. We recommend that the choice of implant be made based on the surgeon’s preference and familiarity with the implant and the patients’ disease state and particularities.
POSITIONING PEARLS
• Carefully protect bony prominences with pillows between the legs, pillows under the proximal fibula, and foam under the nonoperative elbow. • Axillary roll should be used in the lateral decubitus position.
POSITIONING EQUIPMENT
• Suction beanbag • Pillows and foam padding • Radiolucent arm positioner • Use of a sterile tourniquet • High-speed burr • Drill and bits of various size • Oscillating saw • Pulse lavage • Curettes • Appropriately sized humeral and ulnar canal cement restrictors • Pressurized cement gun with appropriate sized nozzle or 60-mL syringe with 10-g 3-inch angiocath • Antibiotic impregnated cement (we routinely use) • Fluoroscopy • Nerve stimulator—this can be helpful in identifying the ulnar nerve in cases of prior trauma or prior transposition
POSITIONING CONTROVERSIES
• Lateral decubitus position • Supine position
PORTALS/EXPOSURES PEARLS
• We use the Bryan-Morrey triceps reflection exposure. • We routinely release the collateral ligaments to increase joint exposure. This is mandatory when operating on a stiff or contracted elbow. PORTALS/EXPOSURES PITFALLS
• Olecranon osteotomy must be avoided. • Inappropriate cleaning of bone debris can predispose the formation of heterotopic bone.
• A radiocapitellar (Coyle) view if necessary (see Fig. 49.1C) • Wrist posteroanterior and lateral radiographs if forearm rotation is deficient and the distal radioulnar joint requires evaluation • Although we do not typically obtain computed tomography (CT) scanning and magnetic resonance imaging (MRI), CT scans with three-dimensional reconstructions can be particularly helpful in complex cases, especially those following trauma. • Wrist radiographs if forearm rotation is deficient and the distal radioulnar joint requires evaluation (see Fig. 49.1D)
SURGICAL ANATOMY • The elbow is a “tie arch” formed by the medial and lateral condyles that contain the articular surfaces. The medial epicondyle serves as an attachment point for the medial ulnar collateral ligament and the flexor-pronator muscle group. The lateral epicondyle is the origin of the lateral ulnar collateral ligament and the extensorsupinator muscle group. • The proximal ulna contains the incisura semilunaris, which is the major articulation of the elbow and is responsible for its inherent stability. Medially, the sublime tubercle is the insertion of the medial ulnar collateral ligament. Laterally, the supinator tuberosity is the insertion of the lateral ulnar collateral ligament. • The elbow joint is classified as a trochoginglymoid joint. The ulnohumeral joint allows flexion and extension, whereas the radiohumeral and proximal radioulnar joints allow for axial rotation. • In the lateral plane, the orientation of the articular surface of the distal humerus is rotated anteriorly 30 degrees with respect to the long axis of the humerus. • The center of the concentric arc formed by the trochlea and capitellum is on a line coplanar to the anterior distal cortex of the humerus. • In the axial plane the articular surface and the axis of rotation is internally rotated 5–7 degrees. • In the coronal plane the articular surface is in 6–8 degrees of valgus. • The carrying angle is the angle formed by the long axis of the humerus and the ulna when the elbow is fully extended. In men the average angle is 11–14 degrees, and in women it is 13–16 degrees. • The median nerve crosses anterior to the brachial artery as it passes across the intermuscular septum. It then follows a direct course into the antecubital fossa, medial to the biceps tendon and the brachial artery. The first motor branch is in the forearm to the pronator teres, through which it passes. • The radial nerve enters the anterior aspect of the arm as it penetrates the lateral intermuscular septum after giving off motor branches to the triceps. At this point, and onward, the nerve becomes at risk for injury during elbow surgery. After penetration of the septum, it descends anterior to the lateral epicondyle, innervating the brachioradialis. In the antecubital space the nerve divides into a superficial branch and deep branch. The deep branch is recurrent, passing deep to the supinator (innervating it). As it courses through the supinator muscle, the nerve lies over a bare area of the radius opposite to the radial tuberosity. Here it is at risk for injury. After emergence from the supinator, the nerve becomes the posterior interosseous nerve. • At the elbow, the ulnar nerve passes into the cubital tunnel under the medial epicondyle and lies against the medial collateral ligament.
POSITIONING • We routinely position patients in the lateral decubitus position (Fig. 49.2). • We routinely use a radiolucent arm positioner to drape the arm over, acting as a stabilizer for the surgery.
PROCEDURE 49 Total Elbow Arthroplasty
477
PORTALS/EXPOSURES CONTROVERSIES
• The management of the extensor mechanism varies by surgeon preference. • Triceps-on, while reducing the risk of triceps insufficiency, does compromise visualization to some extent. • Regardless of exposure choice, visualization of the joint, the proximal ulna, and the distal humeral shaft must be present. • Whether and how to address the ulnar nerve continues to brew controversy. Articles have been published arguing in favor of routine transposition or in situ–only decompression. However, most authors agree that the ulnar nerve should be considered and addressed in some form or fashion. We routinely transpose it subcutaneously.
FIG. 49.2
STEP 1 PEARLS
A
B
C FIG. 49.3 A–C
PROCEDURE
• For skin preparation we prefer chlorhexidinealcohol. • We routinely perform preoperative methicillinresistant Staphylococcus aureus (MRSA) surveillance and pretreat MRSA-carrying patients with 5 days of nasal mupirocin ointment and chlorhexidine baths. • MRSA-carrying patients will receive vancomycin perioperative antibiotics per Surgical Care Improvement (SCIP) guidelines. • We typically use Ioban draping, although care with the incision must be taken because it is not uncommon for the skin to shift excessively to unintended positions. • We incorporate previous incisions where possible.
Step 1: Setup • Regional anesthesia with sedation is used. • A sterile tourniquet is used and set to 75 mm Hg greater than the systolic pressure (see Fig. 49.2).
Step 2: Exposure • Skin is incised down to fascia. Full-thickness flaps are elevated medially and laterally to expose the ulnar nerve and the triceps expansion (Fig. 49.3A). • The ulnar nerve is identified proximal to Osborne ligament, and decompression proceeds from proximal to distal (see Fig. 49.3B and C). • If the nerve is to be transposed (as is routine), the arcade of Struthers must be released and the intermuscular septum must be excised.
STEP 2 PEARLS
• Deformity may alter ulnar nerve position at the elbow. • Careful preoperative examination of the ulnar nerve pathology is mandatory.
STEP 2 PITFALLS
• Maintain the epineural vasculature to the ulnar nerve during transposition. • Avoid the use of a Penrose drain or other fixed retractors on the ulnar nerve.
Step 3: Triceps Elevation • Over the medial aspect of the proximal ulna, the ulnar periosteum is elevated along with forearm fascia (Fig. 49.4A). • The triceps is elevated from the proximal ulna by transecting Sharpey fibers at the site of insertion (see Fig. 49.4B).
STEP 2 CONTROVERSIES
• The skin incision can be straight or curved, depending on the surgeon’s preference.
A
B
C FIG. 49.4 A–C
FIG. 49.5
A B
Excise Triceps attachment
FIG. 49.6 A–B
PROCEDURE 49 Total Elbow Arthroplasty
A
B
C
479
D
FIG. 49.7
STEP 3 PEARLS
• In rheumatoid patients, we release the medial and lateral collateral ligament complexes from their attachments when implanting a semiconstrained, linked prosthesis. The release of collateral ligaments will depend on the prosthesis the surgeon has selected.
A
B FIG. 49.8
• The extensor mechanism, including the anconeus, is reflected laterally to allow complete exposure (see Fig. 49.4C). • The tip of the olecranon is removed (Figs. 49.5 and 49.6).
Step 4: Humeral Preparation • To ensure there is adequate room for instrumentation and the anterior flange, release the anterior capsule from the distal humerus and elevate the brachialis muscle with a broad periosteal elevator (Fig. 49.7). • The midportion of the trochlea is removed with a rongeur or a saw (Fig. 49.8). • The medullary canal is found at the roof of the olecranon fossa and entered with a burr (Fig. 49.9A). • Next, after a pilot hole has been established, the medullary canal is entered with a twist reamer (see Fig. 49.9B). • The medial and lateral aspects of the supracondylar columns should be identified and visualized throughout humeral preparation to ensure proper orientation and alignment. • The alignment stem is placed down the canal, the handle is removed, and the cutting block is attached. Accurate resection of the distal humerus is now possible (Fig. 49.10A). • The side arm of the cutting block is attached to the lateral aspect of the cutting block to the rest on the capitellum and provides the appropriate depth of cut (see Fig. 49.10B). • Using an oscillating saw, the trochlea is removed via the cutting block (see Fig. 49.10C and D).
STEP 3 PITFALLS
• Poor exposure of the joint, proximal ulna and distal humeral shafts may result in inadvertent supracondylar column fracture or cortical perforation.
STEP 4 PEARLS
• Use the most reliable landmark to define the flexion axis. We prefer the anterior cortex to establish the anterior/posterior position, the roof of the coronoid fossa to gauge depth, and the plane of the columns to define the humeral component axis of rotation. • The flat part of the cutting guide should rest on the posterior columns to ensure rotatory alignment of the humeral implant. • Use a burr in a younger patient, especially with posttraumatic conditions, to remove the hard bone just proximal to the olecranon fossa.
STEP 4 PITFALLS
• Violation of either supracondylar bony column when resecting the trochlea can lead to stress risers resulting in supracondylar fracture and subsequent implant failure. The importance of saw control cannot be overemphasized. At times, it may be easier to start or complete cuts with a pencil-tipped burr.
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PROCEDURE 49 Total Elbow Arthroplasty
A
B FIG. 49.9 A–B
A
B
C
D
FIG. 49.10 A–D
STEP 5 PEARLS
• The ulnar medullary canal is identified using a high-speed burr at a 45-degree angle to the base of the coronoid. • Implant rotation is determined by placing the flexion plane perpendicular to the “flat” portion of the proximal ulnar rasp. • If implanting an extra-small ulnar component, the starter rasp should be the final rasp. It should be fully seated to fit the extra-small implant.
FIG. 49.11
Step 5: Ulnar Preparation • Present the ulna and the incisura semilunaris (Fig. 49.11). • If not done already, remove the tip of the olecranon to allow access to the canal. • Identify the medullary canal of the ulna. We use a high-speed burr to open the canal and then enlarge the opening with a combination of the burr, ulnar rasps, and, when indicated, ulnar broaches. • Remove the subchondral bone around the coronoid. • Prepare the proximal canal by using a rasp (Fig. 49.12).
PROCEDURE 49 Total Elbow Arthroplasty
A
B FIG. 49.12
A
B FIG. 49.13
FIG. 49.14
Step 6: Implantation • The first step to a successful implantation is trial reduction. Trial reduction allows assessment of depth insertion and soft tissue restrictions to motion. If the elbow does not fully extend, do not force it into extension. This may drive the humeral implant into the humerus, fracturing the condyles (Fig. 49.13). • During trial reduction, we measure and precut the bone graft for the anterior flange. We use bone graft from the excised trochlea, when possible, or allograft to place anteriorly. Usually the graft measures 2–3 mm thick, 1.5 cm long, and 1 cm wide. • The medullary canals of both the humerus and the ulna should be cleaned and dried. • A medullary cement restrictor should be placed in the humerus (Fig. 49.14). • On the back table, we couple the ulnar and humeral components. They are articulated and connected with the outer, hollow axis pin and the internal, solid pin (Fig. 49.15A and B).
FIG. 49.15 A–B
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PROCEDURE 49 Total Elbow Arthroplasty
FIG. 49.16
FIG. 49.17
STEP 6 PEARLS
• The ulna should be inserted until the center of the ulnar component coincides with the center of the greater sigmoid fossa. • Attention should be given to proper bone grafting anteriorly beneath the anterior flange. This increases the bone stock at the point of maximum stress and helps resist torsional forces associated with loosening. Remember, sometimes bone grafting is unnecessary and doing so will anteriorize the humeral component, preventing complete seating of the component and restoration of the axis of rotation. • When the radial head is degenerative or deformed, the radial head is exposed and excised via a cut made through the neck, just distal to the head. Care must be taken to protect the posterior interosseous nerve. • Take care to remove any excess cement. STEP 6 PITFALLS
• Poor cementing technique
STEP 6 CONTROVERSIES
• Management of the radial head is a topic of continued debate. Some prostheses, such as the Latitude, incorporate radial head arthroplasty. However, this is not the case in most prostheses that are linked. As for unlinked prostheses, the radial head component is hypothesized to decrease the stress on the ulnohumeral articulation, reducing wear, osteolysis, and loosening. In linked implants, the radial head is not necessary for stability. The Coonrad-Morrey prosthesis allows for the presence or resection of the radial head. We believe that management of the radial head should be based on the patient’s disease state. In rheumatoids, the proximal radioulnar joint is often a site of painful synovitis, and resection is necessary. In patients with posttraumatic arthritis or acute fractures, the radial head may be normal and it can be preserved.
FIG. 49.18
• We recommend injection technique for insertion of the cement to ensure a proper mantle. We generally use a 60-mL syringe filled with cement to inject the canals of both the humerus and ulna (Fig. 49.16). • Prior to the cement drying, the ulnar and humeral components are inserted as an articulated unit (Fig. 49.17). • The humerus is positioned down the medullary canal to where the base of the flange is flush with the anterior portion of the coronoid fossa, thus restoring the anatomic axis of rotation. • After the humeral component is inserted into the cement, we place the graft between the anterior cortex and the flange. It is impacted with a bone tamp prior to cement setting. • The elbow is positioned in full extension to fully seat the implants (Fig. 49.18).
Step 7: Triceps Management • We follow the technique well described by Morrey in our repair of the triceps. • We make three drill holes in the ulna: a cruciate and a transverse. • The no. 5 suture is placed onto a Keith needle and passed through one of the cruciate holes. It is then weaved in a Krackow fashion proximally and then distally in the triceps tendon. We pass it back through the other cruciate hole and then through the soft tissue of the distal triceps insertion. Next, it is passed through the transverse hole, and the suture is then tied to itself.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Early satisfaction and pain relief from semiconstrained total elbow arthroplasty (TEA) approaches 90% in most series. • Prosthesis survival at 10 years is 92%, with 86% having good or excellent results in inflammatory arthropathies. • Mean Mayo Elbow Performance Score for follow-up at 10–31 years was 91 in inflammatory arthropathies. • Prosthesis survival at 15 years is 70% in posttraumatic arthritis.
PROCEDURE 49 Total Elbow Arthroplasty
• Infection after TEA occurs in approximately 5% (reported up to 12%) and is strongly associated with postoperative drainage; 20% of patients with postoperative drainage develop an infection. Drainage for more than 10 days postoperatively is very strongly correlated with infection.
EVIDENCE Gill DR, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten- to fifteen-year follow-up study. J Bone Joint Surg Am 1998;80:1327–35. In this 1998 study the authors reported 10- to 15- year follow-up of the Coonrad-Morrey TEA for patients with rheumatoid arthritis from the Mayo Clinic. Mean arc of flexion/extension was 28/131 degrees and pronation/supination 68/62 degrees; 97% of patients had pain relief. The complication rate was 14%, and the overall survival of the prosthesis was 92%. There was an 86% satisfaction rate on the Mayo Elbow Performance Score (MEPS). Kraay MJ, Figgie MP, Inglis AE, et al. Primary semiconstrained total elbow arthroplasty. Survival analysis of 113 consecutive cases. J Bone Joint Surg Br 1994;76:636–40. In this 1994 study the authors reviewed the survival of TEAs in 113 elbows at 3–5-year follow-up. Survival was 92% in inflammatory arthritis. Little CP, Graham AJ, Carr AJ. Total elbow arthroplasty: a systemic review of the literature in the English language until the end of 2003. J Bone Joint Surg Br 2005;87:437–44. In this systemic review, 86 papers reporting the outcomes of 3618 implanted TEAs, with an average of 60-month follow-up, were reviewed. The overall revision rate was 13%. Good to excellent function was reported in 78% of patients. In rheumatoid arthritis, 1093 elbows were reviewed, with a reported revision rate of 10% at 58 months, loosening rate of 12%, and 83% reporting goodexcellent function. In posttraumatic arthritis, 120 elbows were reviewed, with a revision rate of 10% at 99 months, loosening rate of 3%, and 81% reporting good-excellent function. In acute fractures, 79 elbows were reviewed, with a reported revision rate of 3% at 36 months, loosening rate of 0%, and 99% reporting good-excellent function. Sanchez-Sotelo J, Baghdadi YM, Morrey BF. Primary linked semiconstrained total elbow arthroplasty for rheumatoid arthritis: a single-institution experience with 461 elbows over three decades. J Bone Joint Surg Am 2016;98:1741–8. This study reported the outcomes of elbows with a minimum of 2-year follow-up, average of 10year follow-up, and maximum of 30-year follow-up; 11% of elbows required component revision or removal, mostly for mechanical failure. The median MEPS was 90. The rate of survivorship free of implant revision or removal was 92% at 10 years, 83% at 15 years, and 68% at 20 years. Throckmorton T, Zarkadas P, Sanchez-Sotelo J, et al. Failure patterns after linked semiconstrained total elbow arthroplasty for posttraumatic arthritis. J Bone Joint Surg Am 2010;92:1432–41. Eighty-five semiconstrained TEAs were reviewed for posttraumatic arthritis; 68% achieved a good or excellent clinical result, and 74% of patients were satisfied. The 15-year revision-free survival rate was 70%, and 75% of all failures occurred in patients less than 60 years of age.
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STEP 7 PEARLS
• The triceps must be restored to its anatomic position and well secured to ensure a good outcome. • No. 5 nonabsorbable suture is used. • We routinely use a drain to prevent hematoma formation. POSTOPERATIVE PEARLS
• Immobilize in 40 degrees of extension with an anterior plaster shell splint for 24–48 hours with the elbow elevated above the shoulder. • We remove the drain after 24 hours. • We then replace the plaster splint with a bulky dressing to limit postoperative edema but allow for flexion and extension. • At 7 days, normal light use of the elbow for the activities of daily living is permitted. • Sutures or staples are removed at 14 days. • No formal physical therapy is required or indicated. Due to weight-lifting restrictions, strengthening is discouraged. • Patients should avoid lifting with the surgical extremity more than 1 kg on a repetitive basis or more than 4.5 kg on a single event. • If postoperative wound drainage does not resolve within 5 days, we recommend a formal operative debridement, culture, and revision closure of the arthroplasty. • Asymptomatic radiographic lucencies should be observed for progression, but they do not imply implant loosening. • Significant heterotopic ossification is uncommon after arthroplasty. POSTOPERATIVE PITFALLS
• Infection • Ulnar neuropathy • Extensor mechanism failure • Instability • Periprosthetic fractures • Aseptic loosening