Acknowledgments:
We would like to acknowledge the contributions of prior author Leonid Katolik, MD, for his contributions to earlier editions and his insights in developing the current text.
Total elbow arthroplasty (TEA) is increasingly used for the treatment of debilitating elbow arthropathies. Although clinical outcomes following TEA were initially disappointing, modifications in surgical technique and implant design have improved reliability; however, durability with normal loading (>10 pounds) is uncertain. Prosthetic replacement of the elbow relieves pain and typically provides a functional arc of motion, thereby permitting patients to better perform low-load activities of daily living. The longevity of implants in younger patients (those younger than 70 years) is often short, and revision options are limited. Long-term follow-up studies report high rates of revision relative to arthroplasties of the hip, knee, and shoulder. Because of the high potential for mechanical failure and loosening, this procedure should be limited to low-demand elderly patients or those terribly debilitated by pain and instability. It is hoped that improvements in materials, implant design, and surgical technique will one day extend the suitability of TEA to a wider array of pathologic conditions and a broader demographic spectrum.
Rheumatoid Arthritis
Twenty percent of patients with rheumatoid arthritis have arthritic changes in the elbow. As with other major joints affected by rheumatoid arthritis, the elbow undergoes a predictable pattern of intraarticular degeneration of the ulnohumeral and radiocapitellar surfaces, ultimately leading to functional loss in advanced cases. Rheumatoid arthritis has been divided into four stages, based on the physical examination and plain radiographs. Stage I reveals osteoporosis and active synovitis with normal radiographs. Stage II demonstrates chronic synovitis with mild arthritic changes and some loss of joint space. In these early stages, arthroscopic synovectomy can be effective and seems to be more long-lasting in combination with the newer systemic agents. However, regardless of treatment, some patients proceed to complete loss of cartilage with associated pain and loss of strength (stage III). The most severe form (stage IV) demonstrates extensive loss of bone and gross instability ( Figure 27.1 ). It is this last group of patients that derives the greatest benefit from TEA.
Preoperative Evaluation
Multiple Joint Involvement
Before considering TEA in a rheumatoid patient, the patient’s overall status must be considered. If lower extremity joint replacements are planned, use of the affected limb may be needed for assisted ambulation. If shoulder replacement is being considered, this should generally be performed before TEA; surgical access to the elbow will be simpler, and the elbow replacement will not be stressed during shoulder replacement surgery. The cervical spine should be evaluated preoperatively, with special attention placed on atlantoaxial instability.
Physical Examination
Nerve Status.
The status of the radial, ulnar, and median nerves should be assessed and documented before surgery. Rheumatoid arthritis of the elbow can lead to secondary compressive neuropathies of the upper extremity. Antecubital cysts and proliferative synovitis may extend through the joint, compressing the posterior interosseous nerve in the region of the proximal radioulnar joint. Similarly, the ulnar nerve lies along the medial ulnohumeral joint and may be compromised by bony deformity, instability, and direct soft tissue compression from synovitis. A careful neurologic evaluation is thus required in all patients before elbow replacement surgery.
If unconstrained arthroplasty is being considered, it is important to evaluate the integrity of the collateral ligaments. Ligamentous laxity or insufficiency may lead one to consider using a convertible or semiconstrained arthroplasty instead.
Medications.
Patients with rheumatoid arthritis are now being treated with a variety of medications that require management in the perioperative period. It is wise to consult with the patient’s rheumatologist before surgery. Methotrexate can generally be continued during the perioperative period, in the hope of avoiding a flare of inflammation. In contrast, the biologic drugs (anti–tumor necrosis factor agents) are withheld for at least one cycle before surgery and resumed after suture or staple removal. Patients who have been receiving long-term corticosteroid treatment may require stress dosing in the perioperative period. Further study is needed to determine the relative risk of infection and poor wound healing versus stimulating an inflammatory flare by withholding these valuable medications.
Preoperative Planning
Preoperative radiographs should include multiple views of the elbow as well as long-length humerus and forearm films. Views of the contralateral elbow may be helpful for templating if there are large areas of bony destruction in the affected joint. Any arthroplasties of adjacent joints are evaluated for stem length, mode of fixation, and any cement defects. Any areas of cortical thinning should also be noted. For all elbow arthroplasties, preoperative templating should be performed to anticipate stem length and size.
Posttraumatic Arthritis
Posttraumatic arthritis is an increasingly common indication for replacement arthroplasty. The treatment of posttraumatic arthritis must take into account the age and activity level of the patient, degree of impairment, and joint pathologic findings involved. Given the lack of durability of TEA and the propensity for implant failure, techniques such as internal fixation for nonunion and malunion, joint release and débridement, and interposition arthroplasty should be considered in younger, more active adults. Evaluation of the deformity and the quality of the articular surface may require additional radiographic studies in these patients, such as computed tomography. Replacement arthroplasty should be considered when the ulnohumeral joint is no longer salvageable ( Figure 27.2 ). This option is typically limited to individuals older than approximately 60 to 65 years with lower physical demands. However, there may be circumstances in which the impairment and pain warrant the consideration of TEA. Any history of infection after fracture treatment requires careful consideration and may require a staged approach.
Preoperative Assessment
Soft Tissue Envelope
Some patients have had multiple surgeries or flap coverage and incisions should be evaluated carefully. In general, attempts are made to incorporate prior incisions into the approach. If a flap is present, Doppler identification of the flap pedicle may be considered and incisions can be designed to preserve it.
Preoperative Planning
Prior hardware should be noted and preparations for hardware removal should be made, taking into account the hardware manufacturer and the possibility that screws may be difficult to remove, especially if they are made of titanium. Preoperative templating should be used in order to bypass the most proximal humeral or distal ulnar screw hole by two diaphyseal widths if possible.
Fractures of the Distal Humerus
TEA may be indicated for elderly patients with displaced and comminuted fractures of the distal humerus. In the past, the so-called bag-of-bones treatment was recommended because the fracture fragments were too small and the bone too osteoporotic to permit rigid internal fixation. However, this treatment of hopeful neglect frequently resulted in significant pain, stiffness, and decreased function of the hand. TEA after a fracture beyond repair may permit a more rapid return to function. TEA should also be considered in patients with fracture when there is preexisting joint destruction ( Figure 27.3 ). Again, elbow arthroplasty should be limited to older, lower-demand individuals.
Preoperative Assessment
Radiographs
Radiographs of the shoulder and wrist should be performed to screen for other fractures. Radiographs of the elbow should be scrutinized for any extension into the humeral diaphysis that may affect arthroplasty placement. Advanced imaging (computerized tomography) may be used in this regard. It is important to understand the morphologic status of the distal humerus fracture. Injuries with low supracondylar involvement and osteoporotic bone with comminution may be amenable to TEA. Internal fixation is preferred for more proximal fractures, for example, when the transverse limb is proximal to the olecranon fossa.
Fractures of the Distal Humerus
TEA may be indicated for elderly patients with displaced and comminuted fractures of the distal humerus. In the past, the so-called bag-of-bones treatment was recommended because the fracture fragments were too small and the bone too osteoporotic to permit rigid internal fixation. However, this treatment of hopeful neglect frequently resulted in significant pain, stiffness, and decreased function of the hand. TEA after a fracture beyond repair may permit a more rapid return to function. TEA should also be considered in patients with fracture when there is preexisting joint destruction ( Figure 27.3 ). Again, elbow arthroplasty should be limited to older, lower-demand individuals.
Preoperative Assessment
Radiographs
Radiographs of the shoulder and wrist should be performed to screen for other fractures. Radiographs of the elbow should be scrutinized for any extension into the humeral diaphysis that may affect arthroplasty placement. Advanced imaging (computerized tomography) may be used in this regard. It is important to understand the morphologic status of the distal humerus fracture. Injuries with low supracondylar involvement and osteoporotic bone with comminution may be amenable to TEA. Internal fixation is preferred for more proximal fractures, for example, when the transverse limb is proximal to the olecranon fossa.
Primary Osteoarthritis
Primary osteoarthritis of the elbow affects middle-aged and older individuals, primarily men in the fifth decade of life or later; it is rare in women. Most cases involve the dominant side, and many patients report a lifetime of heavy loading. The most common presenting complaint in this population is pain at the extremes of motion, with loss of terminal flexion and extension. Loss of forearm rotation is less common. Intermittent “locking” and pain may be due to loose bodies within the joint.
Individuals with primary arthritis of the elbow typically have bony overgrowth and osteophytes at the coronoid and olecranon processes. Fluffy densities may be observed filling the olecranon and coronoid fossae, and loose bodies can be seen. Narrowing at the radiocapitellar joint is a common finding, although it is not typically symptomatic. The central aspect of the ulnohumeral joint is characteristically spared in this patient population. Pain throughout the entire arc of elbow motion usually signifies synovitis or articular cartilage degeneration in the central ulnohumeral articulation. This is rare and is seen only in late disease.
It must be emphasized that up to 20% of patients with primary osteoarthritis of the elbow have some degree of ulnar neuropathy. The signs and symptoms can be quite insidious and may go unnoticed by the patient until there is substantial nerve dysfunction. The close association of the nerve to the posteromedial joint capsule leaves it susceptible to impingement from osteophytes or from medial joint synovitis expanding the capsule. Early cubital tunnel syndrome in these patients often manifests as pain at the medial elbow. It is thus important to examine these individuals for ulnar nerve irritability and traction signs.
Initial management of primary elbow arthritis consists of activity modification, antiinflammatory medication, intraarticular injection, and, occasionally, therapy. When these modalities prove unsuccessful and symptoms are troublesome, surgical intervention may be warranted. Given the generally young age and high functional demand of patients with primary osteoarthritis at the elbow, prosthetic replacement is usually not recommended. Arthroscopic or open joint débridement and release have traditionally been the primary surgical options because the central ulnohumeral joint space is typically maintained. TEA is reserved for individuals with more advanced arthrosis and lower functional demands who are older than 60 to 65 years. The mechanical failure of TEA in this group of patients has been well documented, so this treatment should be reserved for patients who are willing to reduce their level of activity.
Hemophilic Arthropathy
Patients with hemophilia may present with severe joint destruction as a result of hemophilic arthropathy. Involvement is commonly multiarticular, affecting the shoulders, elbows, hips, knees, and ankles. Potentially severe functional deficits may result. Surgical intervention for hemophilic arthropathy requires a coordinated, multidisciplinary approach. Factor VIII must be supplemented during the perioperative period. Furthermore, the prevalence of human immunodeficiency virus (HIV) in this population predisposes patients to considerable risks, including an increased incidence of secondary infection and a more rapid progression to acquired immunodeficiency syndrome (AIDS) in those with low CD4 counts. Further investigation is needed to define the role of total elbow replacement in treating hemophilic arthropathy.
Preoperative Considerations
Perioperative Management of Blood Clotting
Perioperative management of hemophilia depends on the cause of the clotting disorder. It is important to have the patient’s hematologist involved in blood product management and factor replacement throughout the preoperative and postoperative periods. In classic hemophilia, factor VIII must be supplemented during the perioperative period. In patients with von Willebrand disease, DDAVP or cryoprecipitate may be needed. Preparations with the inpatient blood bank are crucial to ensure adequate blood products are available at the time of surgery. At surgery, careful attention to hemostasis is important to avoid postoperative hematoma. Postoperative drain placement may be considered.
Fractures of the Distal Humerus
TEA may be indicated for elderly patients with displaced and comminuted fractures of the distal humerus. In the past, the so-called bag-of-bones treatment was recommended because the fracture fragments were too small and the bone too osteoporotic to permit rigid internal fixation. However, this treatment of hopeful neglect frequently resulted in significant pain, stiffness, and decreased function of the hand. TEA after a fracture beyond repair may permit a more rapid return to function. TEA should also be considered in patients with fracture when there is preexisting joint destruction ( Figure 27.3 ). Again, elbow arthroplasty should be limited to older, lower-demand individuals.
Preoperative Assessment
Radiographs
Radiographs of the shoulder and wrist should be performed to screen for other fractures. Radiographs of the elbow should be scrutinized for any extension into the humeral diaphysis that may affect arthroplasty placement. Advanced imaging (computerized tomography) may be used in this regard. It is important to understand the morphologic status of the distal humerus fracture. Injuries with low supracondylar involvement and osteoporotic bone with comminution may be amenable to TEA. Internal fixation is preferred for more proximal fractures, for example, when the transverse limb is proximal to the olecranon fossa.
Fractures of the Distal Humerus
TEA may be indicated for elderly patients with displaced and comminuted fractures of the distal humerus. In the past, the so-called bag-of-bones treatment was recommended because the fracture fragments were too small and the bone too osteoporotic to permit rigid internal fixation. However, this treatment of hopeful neglect frequently resulted in significant pain, stiffness, and decreased function of the hand. TEA after a fracture beyond repair may permit a more rapid return to function. TEA should also be considered in patients with fracture when there is preexisting joint destruction ( Figure 27.3 ). Again, elbow arthroplasty should be limited to older, lower-demand individuals.
Preoperative Assessment
Radiographs
Radiographs of the shoulder and wrist should be performed to screen for other fractures. Radiographs of the elbow should be scrutinized for any extension into the humeral diaphysis that may affect arthroplasty placement. Advanced imaging (computerized tomography) may be used in this regard. It is important to understand the morphologic status of the distal humerus fracture. Injuries with low supracondylar involvement and osteoporotic bone with comminution may be amenable to TEA. Internal fixation is preferred for more proximal fractures, for example, when the transverse limb is proximal to the olecranon fossa.
Primary Osteoarthritis
Primary osteoarthritis of the elbow affects middle-aged and older individuals, primarily men in the fifth decade of life or later; it is rare in women. Most cases involve the dominant side, and many patients report a lifetime of heavy loading. The most common presenting complaint in this population is pain at the extremes of motion, with loss of terminal flexion and extension. Loss of forearm rotation is less common. Intermittent “locking” and pain may be due to loose bodies within the joint.
Individuals with primary arthritis of the elbow typically have bony overgrowth and osteophytes at the coronoid and olecranon processes. Fluffy densities may be observed filling the olecranon and coronoid fossae, and loose bodies can be seen. Narrowing at the radiocapitellar joint is a common finding, although it is not typically symptomatic. The central aspect of the ulnohumeral joint is characteristically spared in this patient population. Pain throughout the entire arc of elbow motion usually signifies synovitis or articular cartilage degeneration in the central ulnohumeral articulation. This is rare and is seen only in late disease.
It must be emphasized that up to 20% of patients with primary osteoarthritis of the elbow have some degree of ulnar neuropathy. The signs and symptoms can be quite insidious and may go unnoticed by the patient until there is substantial nerve dysfunction. The close association of the nerve to the posteromedial joint capsule leaves it susceptible to impingement from osteophytes or from medial joint synovitis expanding the capsule. Early cubital tunnel syndrome in these patients often manifests as pain at the medial elbow. It is thus important to examine these individuals for ulnar nerve irritability and traction signs.
Initial management of primary elbow arthritis consists of activity modification, antiinflammatory medication, intraarticular injection, and, occasionally, therapy. When these modalities prove unsuccessful and symptoms are troublesome, surgical intervention may be warranted. Given the generally young age and high functional demand of patients with primary osteoarthritis at the elbow, prosthetic replacement is usually not recommended. Arthroscopic or open joint débridement and release have traditionally been the primary surgical options because the central ulnohumeral joint space is typically maintained. TEA is reserved for individuals with more advanced arthrosis and lower functional demands who are older than 60 to 65 years. The mechanical failure of TEA in this group of patients has been well documented, so this treatment should be reserved for patients who are willing to reduce their level of activity.
Hemophilic Arthropathy
Patients with hemophilia may present with severe joint destruction as a result of hemophilic arthropathy. Involvement is commonly multiarticular, affecting the shoulders, elbows, hips, knees, and ankles. Potentially severe functional deficits may result. Surgical intervention for hemophilic arthropathy requires a coordinated, multidisciplinary approach. Factor VIII must be supplemented during the perioperative period. Furthermore, the prevalence of human immunodeficiency virus (HIV) in this population predisposes patients to considerable risks, including an increased incidence of secondary infection and a more rapid progression to acquired immunodeficiency syndrome (AIDS) in those with low CD4 counts. Further investigation is needed to define the role of total elbow replacement in treating hemophilic arthropathy.
Preoperative Considerations
Perioperative Management of Blood Clotting
Perioperative management of hemophilia depends on the cause of the clotting disorder. It is important to have the patient’s hematologist involved in blood product management and factor replacement throughout the preoperative and postoperative periods. In classic hemophilia, factor VIII must be supplemented during the perioperative period. In patients with von Willebrand disease, DDAVP or cryoprecipitate may be needed. Preparations with the inpatient blood bank are crucial to ensure adequate blood products are available at the time of surgery. At surgery, careful attention to hemostasis is important to avoid postoperative hematoma. Postoperative drain placement may be considered.
Contraindications to Total Elbow Arthroplasty
There are several absolute and relative contraindications to TEA.
Presence of Infection at the Elbow
Any suspicion of infection in the skin, soft tissue, or bone should cause a postponement of the surgery. Patients with rheumatoid arthritis and poor skin quality who are taking immunosuppressive drugs are especially prone to catastrophic postoperative infections. Other sources of bacteria, such as urinary tract infections, should also be screened. If an attempt at internal fixation for fracture has failed, deep infection at the site should be considered, and cultures should be obtained while the patient is free of any antibiotic treatment. The organisms can be quite indolent, especially Staphylococcus epidermidis species.
If active infection is present or even suspected, full débridement of all infected or compromised tissue is required, including all hardware. Trustworthy cultures must be obtained and the proper antibiotics administered through a peripherally inserted central catheter (PICC) line typically for a minimum of 6 weeks. Often a follow-up culture and biopsy of the elbow are obtained after the patient has stopped taking all antibiotics for 6 or more weeks. TEA is considered only after these studies confirm the absence of infection and acute inflammation.
Complete Ankylosis of the Neuropathic Joint
In patients with complete and painless ankylosis of the elbow, implant arthroplasty may not improve overall function. Although a considerable improvement in functional arc of motion has been reported following the conversion of elbow arthrodesis to prosthetic replacement, the nature of the underlying pathologic condition leads to frequent postoperative complications and a less predictable outcome. Total elbow replacement is contraindicated in patients with neuropathic joint destruction owing to their inherent inability to comply with postoperative restrictions.
Poor-Quality Soft Tissue at the Elbow
Severely contracted, scarred, or burned skin needs to be assessed before considering total elbow replacement. For the implant to function properly, the skin and soft tissue need to be pliable enough to permit manipulation for placement of the implant. If there is inadequate soft tissue, a muscle flap should be considered before arthroplasty (see Chapter 44 on soft tissue coverage about the elbow).
Historical Review of Total Elbow Arthroplasty
Elbow arthroplasty has evolved from attempts at resurfacing of the distal humerus or ulna with various materials. Constrained TEA, using a rigid hinge, led to rapid failures. Attempts at distal humeral and proximal ulna resurfacing were commonly complicated by component failure. These prototypes have evolved into the designs used currently ( Table 27.1 ).
| Device and Era | Year of Notable Development | Author | Significance |
|---|---|---|---|
| Hemiarthroplasty, 1920 to 2000s | 1952 | Venable | Metal distal humerus replacement |
| 1965 | Barr and Eaton | Vitallium replacement of distal humerus | |
| 1970 | Johnson and Schlein | Vitallium replacement of proximal ulna | |
| 1971 | Peterson and Janes | Vitallium ulnar “saddle” interposition; limited arc of motion; acceptable longevity | |
| 2011 | Burkhart et al | Convertible hemiarthroplasty for distal humerus fracture | |
| Constrained Arthroplasty, 1970 to 1980s | 1972 | Dee | Hinged total elbow arthroplasty |
| 1982 | Dee | Recognition that rigid hinge has high rate of implant loosening | |
| Surface Replacement Arthroplasty, 1970 to 1990s | 1984 | Rydholm et al | Wadsworth prosthesis had high rates of humeral component loosening |
| 1990 | Kudo and Iwano | 70% of surface replacements had humeral subsidence | |
| Stemmed Unconstrained Arthroplasty, 1970s to 1990s | 1983 | Pritchard | Early experience with stemmed resurfacing arthroplasty of ulna, radius, and distal humerus |
| 1994 | Kudo et al | Titanium-stemmed unconstrained arthroplasty: failures observed at humeral stem junction | |
| 1999 | Trail et al | Souter-Strathclyde unconstrained arthroplasty: flanges into medial and lateral columns for added stability | |
| Stemmed Semiconstrained Arthroplasty, 1970 to Present | 1977 | Schlein | Introduction of semiconstrained prosthesis |
| 1982 | Morrey and Bryan | Recognition that semiconstrained prosthesis has better survivorship than tightly constrained hinge | |
| 1992 | O’Driscoll et al | Anterior flange limits stress on cement interface |
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