Total elbow arthroplasty

1. TOTAL ELBOW
ARTHROPLASTY
PRESENTER : Dr.SUDHEER KUMAR
MODERATOR : Prof.Dr.BIJU RAVINDRAN

2. INTRODUCTION
 Elbow arthroplasty has been described in multiple forms
over time.
 Semi-constrained total elbow arthroplasty, in particular, has
a well-studied track record
 However, the procedure is associated with a relatively high
complication rate
 Not durable as replacements of the hip, knee, or shoulder
 In particular, the excessive loads placed on the device by
high-demand patients is a common cause of failure.

3. GOAL OF TOTAL ELBOW
ARTHROPLASTY
Restore functional mechanics of elbow
 Relief of pain
 Restoration of motion
 Stability

4. IMPLANT TYPES
• Depending on rigidity of fixation of humeral
component to ulnar component
• FULLY CONSTRAINED
• SEMI CONSTRAINED
• UNCONSTRAINED

5. FULLY CONSTRAINED
• Metal to metal hinge with PMMA cement
fixation
• Rarely used now as they have tendency to
loosen & breakage
• Eg: stanmoore.Dee,Mckee.GSB1 & Mazas
designs

6. SEMI CONSTRAINED
• 2 or 3 part prosthesis
• Metal to high density polyethylene
articulation connected with locking
pin or snap-fit device
• Have built in Valgus & varus laxity
for side to side dissipation of forces
• Eg: Coonrad, Mayo, Tri-axial,
Schlein, AHSC Pritchard-walker

7. UNCONSTRAINED
• 2 part prosthesis
• Metal to high density polyethylene articulation without
locking pin or snap-fit link
• Design consists of - stems for humeral component or
resurfacing devices
• Parts unlinked in a attempt to anatomically duplicates
the articular surface of the elbow
• Require normal intact ligaments, anterior
capsule & appropriate static alignment

8. PATIENT SELECTION
It is the most definitive functional procedure for
END STAGE ELBOW ARTHRITIS
• End stage-Rheumatoid Arthritis with radiological
evidence of joint destruction
• Acute unreconstructable fracture > 60 age
• Bilateral elbow ankylosis
• Bony or fibrous ankylosis with elbow in poor functioning
position

9. Contd…
• As a revision of failed elbow arthroplasty
• Loss of bone stock caused by tumour/trauma
• End stage –Osteoarthritis
• Post traumatic arthritis
• Nonunion of distal humerus
• Hemophilic arthropathy

10. IMPLANT SELECTION
Depends to a great extend on the
 Fate of capsuloligamentous structures about the elbow
 Integrity of the musculature
Amount of bone remaining at the elbow joint
• Resurfacing /unconstrained prosthetic designs-patients with
a more stable joint with more bone remaining
• Semi-constrained- patients with extensive injury to ligaments
& capsule of joint, atrophic musculature & loss of considerable
bone stock

11. CONTRAINDICATIONS
• Active or recent elbow Sepsis(absolute)
• Poor soft tissue envelope
• Non restorable function of Biceps & Triceps
• Poor patient compliance with activity & weight lifting
restrictions
• Flaccid paralysis of upper extremity
• Young vigorous patient with a post traumatic destroyed elbow
• Neuropathic elbow joint
• Ankylosis of Ipsilateral shoulder

12. PRE-OP PLANNING
• Routine AP & lateral radiographs
 Assess humeral bow & medullary canal size in
lateral projection
Note size & angulation of the ulnar medullary canal
In both projection
• Templates are available for all the varying size prostheses &
very useful
• Ulnar nerve examination-document if any degree of
impairment noted
• Elbow aspiration & culture to rule out joint sepsis –if infection
is suspected or rheumatoid elbow is red/hot/swollen

13. COONRAD-MORREY PROSTHESIS
• Semi-constrained hinged prosthesis
• High-molecular-weight polyethylene bushing & titanium
humeral and ulnar components.
• Designed with 7 * of rotary and side-to-side laxity.
• Humeral and ulnar stems match the shapes of the
medullary canals.
• The triangular humeral stem is flattened near the base at
the inferior flatter and wider portion of the medullary canal
of the humerus.

14. • The large medullary stem enhances rigid fixation.
• Its long stem, contour & distal anterior flange increase
resistance to torque.
• Careful bone removal in the intercondylar area of the
humerus is necessary to allow a tight fit of the humeral
prosthesis.
• Prosthesis usually is inserted with the elbow fully flexed
• Components also can be inserted separately and then
joined.
• Right & left prostheses are available as trial components.

18. POST OP IMAGING
• AP and lateral films are obtained as baseline reference
• used for future comparison to follow up studies to document
stability of prosthesis.
• Initial radiographs are scrutinized for:
• Alignment
▫ Humeral and ulnar stems should align with the long axis of
the bone
▫ Humeral and ulnar components show normal articulation
without evidence of dislocation

19. • Peri-prosthetic fractures
• Cement technique
▫ Cement should coat the prosthesis stems without
extravasation into soft tissues
▫ Intraoperative fractures or osteopenic bone increase risk
of cement leak which may damage radial or ulnar
nerves.

20. POST OP CARE
The extremity is elevated overnight with elbow above
the shoulder.
The drains & compressive dressing are removed the day
after surgery.
A light dressing is then applied & passive elbow flexion
and extension are allowed as tolerated.
 A collar and cuff are used & instructions in the activities
of daily living are provided by an occupational therapist.

21.  Active elbow extension must be avoided for
3 months until the triceps heals.
 Strengthening exercises are avoided.
Patient is encouraged to avoid lifting more than
5 lb for the first 3 months after surgery
Thereafter, lifting is restricted to 10 pounds

22. RESULTS
• RATING SYSTEM OF MORREY
used 3 criteria to rate TEA
Xray appearance
pain
motion
1.GOOD RESULT
No radiographic change at the bone cement /prosthesis
interface
No pain
>90* of flexion
60* of pronation & supination

23. 2.FAIR RESULTS
• > 1mm of widening of any bone cement prosthesis
interface
• Mild pain
• Between 50* & 90* of flexion & extension
• Less than 40* of pronation & supination
3.POOR RESULTS
• >2mm of widening of any bone cement prosthesis
interface
• Pain that significantly limits activity
• Less than 50* of flexion & extension
• Revision of elbow arthroplasty

25. PAINFUL OR FAILED ELBOW
ARTHROPLASTY
• Evaluated with serial conventional radiographs
• May be due to a variety of problems. These include:
• Instability
• Polyethylene problems
• Osteolysis
• Loosening
• Infection
• Fractures
• Heterotopic ossification

27. INSTABILITY
• Instability occurs in the form of dislocation or subluxation
• Most common complication requiring revision of
unconstrained prostheses
• reported to occur in between 9% and 10% of total elbow
arthroplasties
INTRA-OP PRECAUTIONS
• Appropriate tensioning of the medial & lateral ligament
complexes
• preservation of the anterior capsule and triceps

28. INSTABILITY
• Instability in SEMI-CONSTRAINED TEA is usually caused
by
wear of the polyethylene bushings or
disengagement of the linkage pin.
• Proper prosthesis alignment is crucial in linked
arthroplasty.
• Malalignment can cause abnormal forces to be generated
across the joint which can lead to early hardware failure.

29. Polyethylene Problems
• Polyethylene components are prone to wear after long
term usage.
• Wear and the subsequent debris that it produces initiate
synovitis and foreign body reaction, which can ultimately
lead to severe bone loss.
• In many linked arthroplasty prostheses models,
bushings are made of polyethylene.
• A bushing is defined as a fixed or removable cylindrical
lining used to reduce friction between the humeral and
ulnar components.

30. Polyethylene Problems
• Bushing wear is determined on an AP radiograph.
METHOD:
• A line was drawn parallel to the yoke of the humeral
component, & another line was drawn parallel to the
medial or lateral surface of the ulnar component.
INFERENCE :
• An angle of intersection > 7 * indicates excessive tolerance
of the bushings due to polyethylene deformation

31. Polyethylene Problems
• Certain factors are associated with the development
of bushing wear. They are
• younger patient age,
• male sex,
• Post traumatic arthritis,
• Pre operative elbow deformity,
• Supra condylar nonunion,
• high activity levels

32. Osteolysis
• Refers to both focal and linear periprosthetic bone loss
adjacent to any joint replacement
• Results from a foreign body response to particulate debris
from the wear of arthroplasty components and cement
• Particles are taken up by macrophages & giant cells which
may release cytokines that initiate a cascade reaction
ultimately resulting in osteolysis

33. • Osteolysis is usually asymptomatic.
• Follow-up radiographs are used to identify the
process early
• Thinned cortex and weakened bone places patients at
risk of pathologic fracture, prosthesis subsidence and
loosening
• Large amounts of particulate may dissolve in joint
fluid, staining the fluid and synovium a dark metallic
color. This is called metallosis

34. Aseptic Loosening
• Failure of the bond between an implant and bone in the
absence of infection.
• It is the most frequent cause of long-term implant failure
RISK FACTORS:
patients who continue to use their elbow in
strenuous activities and heavy lifting
constrained, linked prosthesis types.
• Presents with insidious onset of activity related pain in a
previously well functioning prosthesis.

35. Aseptic Loosening
Radiographic signs of loosening include:
Progressive and extensive widening of interfaces
between bone-cement, bone-prosthesis, or cement-prosthesis
Fragmentation or fracture of cement
Migration/subsidence of prosthetic components
Bead shedding in porous-coated prostheses

36. Marked loosening of humeral stem with migration
antero-laterally beyond the humeral cortex.

37. INFECTION
• Infection rates after TEA remain greater than those for total
hip or knee arthroplasties.
• Reason:
relative paucity of soft tissue coverage in the
elbow compared to the other joints.
• Typical infecting organisms are
Staphylococcus aureus ,
Staphylococcus epidemidis

38. INFECTION
• Risk factors : oral steroid use, diabetes mellitus, distant
osteomyelitis, infected prostheses at other sites &
H/O septic arthritis in the affected elbow.
Clinical signs and symptoms may consist of
• Pain
• Decreasing range of motion
• Fever
• Night sweats
• Chills
• Erythema
• Draining sinus tract

39. Radiographic features of infection include:
• Progressive and extensive widening of interfaces
between bone-cement, bone-prosthesis or cement-prosthesis
• Periosteal bone formation
• Periprosthetic bone resorption
• Soft tissue or periprosthetic gas

40. Infected total elbow arthroplasty. There is a large joint effusion (red arrow),
distended olecranon bursa (O), and irregular interface widening about the
ulnar stem (green arrow).

41. INFECTION
• Infection of elbow replacements requires aggressive
treatment with Antibiotics
Surgical management may consist of:
• Irrigation and debridement
▫ Considered when infection is acute
▫ May require repeat procedures, placing patient at risk for
soft-tissue damage
• Resection arthroplasty
▫ Hardware removed and antibiotic impregnated cement
space placed
▫ Eventually followed by revision arthroplasty

42. • Cement spacers are temporary prostheses made of
antibiotic impregnated methylmethacralate.
• The cement is prepared in the surgical site, mixed with
antibiotics, and formed by the surgeon into forms
resembling the components of the elbow arthroplasty.
Advantages :
• Provide local dispersal of antibiotics to the infected joint
area
• Maintain length
• Minimize dead space
• Preserve soft-tissue planes
• Facilitate ease of revision arthroplasty

43. PERIPROSTHETIC FRACTURES
• The rate of periprosthetic fractures after elbow arthroplasty vary
from 6% to 22%
• Classified using Mayo classification of periprosthetic
fractures after elbow arthroplasty
Fractures are classified according to
• location
• bone quality
• whether component is stable or loose
• Classification of the humerus and ulna are determined
separately.

44. Mayo classification of periprosthetic fractures after
elbow arthroplasty