Elbow Arthroplasty

Constrained – used only in cases of severe bone loss due to high loosening rate

Semi-constrained – eg. Coonrad-Morrey – most commonly used, sloppy hinge providing some varus & valgus motion

Unconstrained – eg. Capitellocondylar – unlinked metal on poly articulation, require normal ligaments

Fascial – coverage of articulation with fascia lata autograft

Complications – in implant arthroplasty, humeral loosening is most common in semiconstrained prosthesis (5%), infection (5%), nerve injury (11%), wound problems (14%) and instability of unconstrained prosthesis (9%)

To minimize risk of complications – longitudinal posterior approach medial to olecranon, transpose ulnar nerve, suction drain, splint in extension

 

Indications

Excision arthroplasty – refractory sepsis, failed total elbow

Fascial arthroplasty – young patients with post-traumatic arthritis, with pain & stiffness

Implant arthroplasty – pain, instability & bilateral joint ankylosis, ankylosis in non-functional position, rheumatoid arthritis (better prognosis than post-traumatic arthritis)

 

Fascial Arthroplasty

 

• lateral position
• posterior approach
• identify & protect ulnar nerve (mobilize and transpose subcutaneously at end of case)
• triceps splitting approach – dissect subperiosteally medially & laterally off distal humerus
• debride distal humerus & fashion articular surface into inverted V
• deepen trochlear notch of ulna and resect radial head
• obtain rectangle of fascia lata & fold it in half
  • suture apex to anterior capsule
  • proximal half over distal end of humerus
  • distal half over trochlear notch of ulna

 

TEA (Coonrad-Morrey)

 

• GA
• patient supine with sandbag under shoulder (or lateral), arm across chest
• sterile tourniquet, posterior incision, mobilize and protect ulnar nerve for later transposition
• elevate triceps off olecranon and ulna, release medial collateral ligament from medial epicondyle and rotate forearm to expose humerus
• Alternately do triceps tongue (may better preserve elbow extension)
• use oscillating saw to remove bone from trochlea and olecranon fossa, burr to expose intramedullary canal
• hand ream then apply cutting guide to distal humerus (appropriate side on capitellum)
• remove bone from distal humerus to allow for seating of trial prosthesis with margins of prosthesis at level of epicondylar articular surface margins
• burr and rasp medullary canal of ulna (appropriate size)
• preserve the radial head if possible, fashion bone graft from articular surface of humerus to place between bone and anterior flange
• cement ulna first then humerus with axle at level of anatomic axis of elbow, reattach triceps expansion with drill holes through bone
  • use antibiotic-impregnated cement because of higher risk of infection vs. TKA /THA
• drains then immobilize elbow in extension