Total Elbow Arthroplasty

Peter Johnston, MD

Matthew L. Ramsey, MD

Dr. Ramsey or an immediate family member has received royalties from Integra LifeSciences and Zimmer; serves as a paid consultant to or is an employee of Integra LifeSciences and Zimmer; has received research or institutional support from Integra LifeSciences and Zimmer; and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the Philadelphia Orthopaedic Society, the Rothman Institute, and the Rothman Specialty Hospital. Neither Dr. Johnston nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

INTRODUCTION

A functional, pain-free elbow joint is dependent on the integrity of the ulnohumeral articulation. Diverse pathology exists that ultimately leads to destruction of the ulnohumeral joint and manifests as painful motion, instability, or ankylosis. The degree of functional limitation is dependent on the severity of bony destruction and the involvement of soft-tissue structures, which vary with the underlying pathology.

Current total elbow arthroplasty (TEA) implant designs are categorized as linked (coupled), unlinked (uncoupled), and hybrid linkable. The decision to use a linked versus an unlinked implant is dependent on the underlying pathology, the adequacy of bone stock, and the integrity of the ligamentous soft-tissue envelope. Unlinked implants require joint stability and bone stock adequate to support the implant, narrowing the indications, but provide a theoretical decrease in stress across the prosthesis and lower loosening rates when compared with a linked joint. Unlinked implants are suitable for pathologies with intact supracondylar columns, minimal subchondral bony deformity, and competence of collateral ligaments. Linked implants are joined by a “sloppy hinge,” which allows slight movement in the varus-valgus and axial planes. Indications for linked implants are broader, including ligamentous deficiency and traumatic conditions with severe bone loss, which include acute fractures, established posttraumatic arthrosis, distal humeral nonunion, posttraumatic ankylosis, posttraumatic instability, and revision TEA. Hybrid linkable implants permit implantation in an unlinked fashion, taking advantage of the benefits of an unlinked implant, but can be easily converted to a linked implant if stability cannot be established at initial implantation or if instability becomes an issue remote from the index arthroplasty.

PATIENT SELECTION

Contraindications

The absolute contraindications to total elbow arthroplasty are infection of the joint as well as lack of motor function necessary to provide active elbow flexion. With regard to relative contraindications, TEA should be avoided in younger patients, particularly in laborers who are better candidates for nonarthroplasty options. TEA in the setting of a neuropathic joint will lead to unpredictable outcomes and a high complication rate. Additionally, TEA should be avoided in patients who are unwilling to live within the activity and weight restrictions that are requirements for implant longevity.

Implant-specific contraindications exist for unlinked implants. These implants should be avoided in situations where the bony architecture or the collateral ligaments will be compromised during surgery or may develop in the postoperative period. These situations, which should be treated with a linked implant, include takedown of an elbow arthrodesis or painless ankylosis, tumor resection of the distal humerus, gross deformity that interferes with soft-tissue balancing, and excision of heterotopic ossification.

PREOPERATIVE IMAGING

Standard radiographic evaluation of the elbow joint includes AP, lateral, and oblique radiographs (Figure 1). These views are usually sufficient to assess bone quality and the degree of bony abnormality, providing the surgeon with information guiding implant selection (linked versus unlinked) and sizing. Additionally, stress radiographs can be taken if there is a suspicion of ligamentous instability.

CT usually is not necessary in the preoperative workup of patients with underlying arthritides, but it can provide
the surgeon with additional information on joint or periarticular deformity. CT can be particularly useful in the acute fracture setting, in managing malunion or nonunion, or in cases with heterotopic ossification. MRI has a limited role in the preoperative diagnostic workup for TEA.

FIGURE 1 AP (A), lateral (B), and oblique (C) radiographs of the elbow of a patient with rheumatoid arthritis demonstrate joint destruction and cyst formation in the capitellum severe enough to consider total elbow arthroplasty.

Preoperative Evaluation

Prior to surgery, a detailed examination is performed with attention to the status of the overlying skin, prior incisions, contractures, limb alignment, joint stability, and flexion-extension arc. If prior surgery has been performed, the location of the ulnar nerve should be considered as well as the presence of ulnar nerve symptoms.

Preoperative Planning

Preoperative radiographs, any underlying pathology, and surgeon experience should guide the selection of a linked versus an unlinked implant. It is important to recognize that if an unlinked system has been selected, a linked system should be available in case it becomes apparent that an unlinked system will not stabilize the elbow. A linkable system allows easy conversion from an unlinked to a linked arthroplasty.

PROCEDURE

Room Setup/Patient Positioning

The patient is positioned supine on the operating room table with a bump placed beneath the ipsilateral scapula, and the arm is placed on a bolster across the chest (Figure 2). The bump allows the arm to be easily draped across the chest throughout the procedure. A well-padded tourniquet is placed on the upper arm of the surgical extremity. A sterile tourniquet will increase the zone of sterility and is preferred at our institution. The arm is draped free up to the shoulder.

Surgical Technique

After the extremity is exsanguinated and the tourniquet is inflated, a straight posterior skin incision is made just
off the tip of the olecranon extending approximately 9 cm proximal and 8 cm distal to the olecranon (Figure 3). Subcutaneous flaps are elevated but not in excess of what is needed for exposure because elderly patients and those with rheumatoid arthritis are at risk for wound complications. A subcutaneous pocket is created for subcutaneous transposition of the ulnar nerve, which should be performed in all cases. In primary surgery, the ulnar nerve is carefully identified and mobilized from its proximal location at the medial aspect of the triceps (arcade of Struthers) to the first motor branch to the flexor carpi ulnaris (FCU). A Penrose drain or vessel loop is placed around the nerve to facilitate dissection. A 1-cm portion of the distal medial intermuscular septum is excised to prevent nerve constriction as it passes anteriorly for the transposition (Figure 4). If the nerve has been previously transposed, its location is identified but no formal dissection is performed unless necessary for exposure to avoid nerve injury.

FIGURE 2 Illustration shows patient positioning for total elbow arthroplasty.

FIGURE 3 Photograph shows the skin incision for total elbow arthroplasty marked on a left elbow. Note that a straight incision is made just off the medial aspect of the olecranon. (Reproduced with permission from Morrey BM: Semiconstrained total elbow arthroplasty, in Morrey BF, ed: Master Techniques in Orthopaedic Surgery: The Elbow. Philadelphia, PA, Lippincott Williams & Wilkins, 2002, p 315.)

Management of the triceps is guided by the underlying pathology, the type of implant to be used, and surgeon preference. Triceps insufficiency is a recognized but underappreciated complication of triceps-reflecting approaches.¹ Therefore, every effort is made to maintain the integrity of the triceps insertion. Several approaches are used in TEA, each with advantages and disadvantages. The traditional Mayo triceps-reflecting approach (Bryan-Morrey) and triceps-on approach will be described in detail.

FIGURE 4 Intraoperative photograph demonstrates resection of the medial intramuscular septum. The ulnar nerve has been transposed into an anterior subcutaneous pocket. (Reproduced with permission from Morrey BF: Semiconstrained total elbow replacement, in Morrey BF, ed: Master Techniques in Orthopaedic Surgery: The Elbow. Philadelphia, PA, Lippincott Williams & Wilkins, 2002, p 316.)

Bryan-Morrey Triceps-Reflecting Approach

The Bryan-Morrey triceps-reflecting approach is performed by reflecting the triceps tendon, forearm fascia, and periosteum as one unit from medial to lateral off the olecranon.² The medial aspect of the triceps is elevated off the posterior humerus to the tip of the olecranon. The superficial fascia between the anconeus and the FCU is incised from the posteromedial border of the ulna distally. The triceps in continuity with the anconeus is subperiosteally elevated from the tip of the olecranon from medial to lateral as a single layer (Figure 5). Further lateral elevation of the triceps-anconeus exposes the radiocapitellar joint. The lateral and medial collateral ligaments are released from their origin on the humeral epicondyle. This allows the ulnohumeral joint to be dislocated, exposing the articular surfaces of the elbow. If ligamentous integrity is necessary (unlinked arthroplasty), then the lateral ulnar collateral ligament and the medial collateral ligament should be tagged so they can be reattached via bone tunnels in the humerus during closure. To improve visualization of the distal humerus, the tip of the olecranon can be removed with a rongeur (Figure 6). Finally, the shoulder is externally rotated and the elbow is flexed, allowing the ulna to separate from the humerus.

Triceps-Sparing Approach

The triceps-sparing (triceps-on) approach is an excellent option for management of acute fracture and cases of humeral nonunion; it is our preferred approach with a linked implant.³^,⁴ The medial and lateral borders of the triceps are identified, and the triceps is completely mobilized bluntly from the posterior humerus to the proximal
ulna (Figure 7). The triceps is separated from the underlying joint capsule, which is resected to aid exposure. The flexor-pronator group and the medial collateral ligament are subperiosteally dissected from the medial epicondyle. In a similar fashion, the common extensor tendons and the lateral collateral ligament complex are released from the lateral epicondyle. Through the medial and lateral windows, the anterior capsule is released. This completes the circumferential release of the elbow, allowing the joint to be dislocated. The humerus is delivered through the lateral triceps defect to permit bony preparation. Exposure to the ulna for preparation and instrumentation is attained by supinating the forearm, turning the triceps back on itself. This is the most challenging aspect of this approach.

FIGURE 5 The Bryan-Morrey triceps-reflecting approach. A, Illustration shows that the triceps in continuity with the anconeus is reflected from the ulna. B, Intraoperative photograph demonstrates the Bryan-Morrey approach. C, Illustrations demonstrate that further elevation laterally allows identification of the radiocapitellar joint. The lateral (D) and medial (E) collateral ligaments are released, allowing dislocation of the joint. (Panel B adapted with permission from Morrey BM: Semiconstrained total elbow arthroplasty, in Morrey BF, ed: Master Techniques in Orthopaedic Surgery: The Elbow. Philadelphia, PA, Lippincott Williams & Wilkins, 2002, p 317.)

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