Total Elbow Arthroplasty

Chapter 4 Total Elbow Arthroplasty

Aviva Wolff, OTR/L, CHT

The primary goal of total elbow arthroplasty (TEA) is pain relief with restoration of stability and functional motion (arc of 30 to 130 degrees). An elbow replacement is considered when the joint is painful, is restricted in motion, and has destroyed articular cartilage. Patients who are elderly or have low demands that present with rheumatoid arthritis, advanced posttraumatic arthritis, advanced degenerative arthritis or nonunion, and comminuted, distal humeral fractures are good candidates for this surgery. A total elbow replacement is contraindicated in situations where there is active sepsis in the joint, previous infection or open wounds at the elbow, poor soft tissue envelope, skeletal immaturity, and paralysis of biceps or triceps. Complications of this surgery include delayed wound healing, infection, ulnar neuritis, triceps insufficiency, instability, and mechanical failure.

Surgical Overview

• TEA includes three types of implants: constrained, nonconstrained, and semiconstrained.

1 The first prosthesis developed was rigid and fully constrained. It had a metal-to-metal interface and provided immediate stability, but had a high failure rate with loosening occurring after several years.

2 This was followed by a nonconstrained implant, which is composed of two separate units and is a resurfacing of the distal humerus and proximal ulna.

– This design requires strong ligaments, good bone quality, and adequate soft tissue support and is therefore only indicated in a select group of patients.

– Examples include capitellocondylar, Kudo, and Souter implants.

1 The latest semiconstrained design, referred to as a “sloppy hinge,” is the most popular.

– Although it provides stability similar to the constrained implant, its “toggle” characteristic allows for varus–valgus play and axial rotation.

– This type of design reduces some of the problems related to the constrained device.

– Examples include the Coonrad-Morrey and GSB 3 (Gschwend) implants.

• The choice for a specific implant is based on the extent and cause of the disease, the specific needs of the patient, and the surgeon’s preference.

• At the Hospital for Special Surgery (HSS), the Coonrad-Morrey semiconstrained total elbow prosthesis (Zimmer, Warsaw, IN) is most frequently used. When a nonconstrained implant is indicated, the capitellocondylar implant is most often used.

Rehabilitation Overview

• Progression of therapy is based on the stages of wound healing and is affected by implant type, skin integrity, rate of healing, and the preoperative and postoperative condition of the triceps.

• Timeframes may be delayed to allow for wound closure and adequate healing of the triceps in patients with poor soft tissue quality, as is common in rheumatoid arthritis (RA).

• Each surgeon has different preferences in the type of implant, surgical technique, and postoperative treatment. The referring surgeon is consulted for specific range of motion (ROM) restrictions and time frames.

• The guidelines below are for semiconstrained total elbow replacements performed with the triceps sparing approach.

1 This technique was developed to avoid complications such as triceps avulsion, triceps weakness, and wound healing problems.

2 Notes in italic refer to guideline modifications for nonconstrained TEA. Timeframes may be delayed in these implants to allow for adequate stability.

Postoperative Phase I: Inflammation/Protection (Weeks 0 to 2)

GOALS

• Protective immobilization

• Wound healing and closure

• Control of edema and inflammation

• Full ROM of proximal and distal joints

• Full elbow ROM within protected arc

Tags: Handbook of Postsurgical Rehabilitation Guidelines

Jun 22, 2016 | Posted by admin in PHYSICAL MEDICINE & REHABILITATION | Comments Off

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