Total Elbow Arthroplasty

       Total Elbow Arthroplasty

                            DR KS DHILLON

Introduction

Total elbow replacement was initially developed to manage end-stage rheumatoid arthritis of the elbow [1]. Over the years the indications have expanded to include comminuted fractures, osteoarthritis, and posttraumatic arthritis of the elbow [2-10]. It is sometimes also indicated for juvenile idiopathic arthritis, hemophilic arthropathy, and primary or metastatic tumors. 

With total elbow replacement, long-term complications, such as infection, instability, aseptic loosening, and periprosthetic fracture, remain a problem [11-16]. 

Total elbow arthroplasty is a relatively rare procedure and most surgeons do not have much experience with the procedure. Furthermore, there is a lack of long-term outcome data for elbow arthroplasty.

History of total elbow replacement  

The elbow joint has been widely regarded as homologous to the knee joint. The original uniaxial hinge design of the joint replacements developed for total elbow replacement in the late 1960s was exactly the same as those developed for total knee replacement. The initial results of these replacements were good but there were early failures due to implant wear and loosening.

During the 1970s, designs of knee replacement evolved from uniaxial hinges into unlinked components that relied upon the ligaments for stability, and then into the more intrinsically stable condylar-shaped designs, similar to those used today.

The development of total elbow replacement went from the uniaxial hinge design to a less constrained hinge (linked) design to unlinked design where the components were not joined by an axle mechanism. In the linked designs components are unlikely to dislocate or disassociate. With the unlinked design component dislocation and dissociation can be a problem.

The Kudo prosthesis was first reported in 1990 and is one of the most popular unlinked total elbow designs. The unlinked total elbow has no mechanical connection between the humeral and ulnar components and hence has advantages of near normal elbow kinematics and preservation of bone stock. The unlinked design was developed to overcome loosening of the hinge prosthesis. The unlinked prosthesis is suitable only for patients with limited bone loss or limited deformity and good ligament function. 

They have low intrinsic stability and rely on the medial and lateral collateral ligaments, the posterior capsule, and surrounding muscles for stability.

The Linked Semiconstrained Design (Coonrad-Morrey) is a semi-constrained design featuring a central cylindrical bearing and two side bearings. It is one of the most frequently used devices for elbow replacement. It allows some varus-valgus motion which reduces stress concentration on the bone-cement interface. This design has been used to treat conditions such as degenerative arthritis, rheumatoid arthritis, and elbow fractures. Satisfactory outcomes have been reported with long-term follow-up [17-21]. Aseptic loosening with bushing wear is a leading complication. 

The Discovery Elbow System is a semi-constrained condylar bearing design. It is a hemispherical linked prosthesis designed to reduce complications such as bushing wear associated with the semiconstrained prosthesis. It does not have a true hinge, and it anatomically reproduces the axis of elbow motion. Its floppy hinge allows for 6°–8° of varus-valgus and rotational motion.

More recently a convertible design (Latitude System) has been developed that allows the surgeons to choose between a nonconstrained and semiconstrained prosthesis [22,23]. A semi-constrained hinge can be created by applying a modular component to the ulnar prosthesis if the surgeon has concerns regarding collateral ligament insufficiency or implant stability. The 2-year follow-up outcome of the convertible elbow prosthesis was comparable with historical controls. However, no long-term follow-up data is available [22,23].

Clinical Outcomes and Survival Rates

Welsink et al [24] carried out a systematic review of total elbow arthroplasty. Their review included 73 articles involving a total of 9,379 elbow arthroplasties. The level of evidence was primarily Level IV. 

Nineteen different designs of total elbow arthroplasty implants are included in the review. The most common indication for elbow arthroplasty was rheumatoid arthritis (70%). 

The weighted mean survival rate for the linked prosthesis was 85.5% at 7.8 years and for the unlinked prosthesis 74% at 12.3 years. The range of motion after elbow arthroplasty was good overall, with a mean flexion of 129° and a mean extension lag of 30°. The complication rates ranged from 11% to 38%. Clinical loosening was the most frequent complication (7%).

The results of elbow arthroplasty are respectable overall. There are small differences between designs. The survival and complication rates are still not as favorable as those following arthroplasties in other joints.

Prkic et al [25] carried out a systematic review on modes of failure of total elbow arthroplasty. Seventy articles were included in the systematic review. A total of 9308 individual total elbow arthroplasties were identified with 1253 revisions (13.5%). The most prevalent reason for the revision was aseptic loosening (38%), followed by deep infection (19%) and periprosthetic fractures (12%).

The revision rates for rheumatoid arthritis are significantly higher than for trauma and post-traumatic osteoarthritis. Aseptic loosening is less in linked implants. Infections and periprosthetic fractures did not differ between the linked and unlinked designs. 

Krukhaug et al [26] using data from the Norwegian Arthroplasty Register from 1994 to 2016, reported that overall outcomes and survival rates of elbow arthroplasty showed an overall 5 years, 10 years, 15 years, and 20-year survival rates of 92%, 81%, 71%, and 61%, respectively. They found that risk factors for revision were a diagnosis of sequelae after trauma and cementless fixation of the ulna component. They also found that the most frequent reason for revision surgery was aseptic loosening, followed by defective polyethylene, dislocation, and infection. The causes of revision were to some degree implant specific.

Rheumatoid Arthritis (RA)

The incidence of elbow arthroplasties performed for inflammatory arthritis is decreasing. This is probably due to the efficacy of disease-modifying antirheumatic drugs [14,24]. Despite this progress in the medical treatment of RA, there still are severe cases who need elbow arthroplasty.

Hildebrand et al [27] in a study reported a mean patient satisfaction of 9.2 out of a possible 10 points on the functional outcome of patients with inflammatory arthritis who underwent elbow arthroplasty.

 A study by Mansat et al [28] showed that the treatment outcome after elbow arthroplasty for RA with a minimum 2-year follow-up had a 97% survival rate at 5 years and 85% at 10 years. At an average of 7 years of follow-up (range, 2–16 years), the mean Mayo Elbow Performance Score (MEPS) was 91 points (range, 55–100 points), and the shortened version of the Disabilities of the Arm, Shoulder, and Hand score was 34 points (range, 0–75 points). There was a significant improvement in the MEPS and in all range of motion scores at the latest follow-up in comparison to preoperative values.

Distal Humerus Fracture

Many surgeons now select elbow arthroplasty to treat comminuted distal humerus fractures. The indications for elbow arthroplasty for trauma-related disease has expanded [5,7-9,29-33].

Long-term outcomes for elbow arthroplasty are not available due to the paucity of data. Hence, the use of elbow arthroplasty for treatment in young individuals is debatable [32,33].

Rajaee et al [9] compared elbow arthroplasty with open reduction and internal fixation using data obtained from the Nationwide Inpatient Sample for 2002–2012. The data showed that the annual frequency of elbow arthroplasty increased 2.6-fold in elderly patients with distal humerus fractures, and elbow arthroplasty is the preferred treatment alternative to internal fixation in elderly patients with complex distal humerus fractures that are not amenable to a stable fixation.

Barco et al [34] in a study of 44 elbow arthroplasties after distal humeral fracture reported that the mean visual analog scale score for pain was 0.6, the mean flexion was 123°, and the mean loss of extension was 24°. The mean MEPS was 90.5 points, with three patients scoring less than 75 points.

Posttraumatic Arthritis

Total elbow arthroplasty is a treatment option for advanced posttraumatic arthritis of the elbow. The outcome, however, is not satisfactory when compared to other indications [20,24,35-38]. 

Patients with posttraumatic OA typically have more than 1 previous surgery with scars and severe limitation of movements due to soft-tissue contraction. This leads to difficulty in approaching and managing the soft tissue. The prognosis is worse in patients who develop traumatic arthritis after fracture than in patients with inflammatory arthritis [26,39,40]. 

Hildebrand et al [27] reported the functional outcome of elbow arthroplasty in patients with posttraumatic arthritis. They found that the mean score on the Mayo Elbow Performance Index was significantly higher for the group with inflammatory arthritis than for the group with a traumatic or posttraumatic condition at the latest follow-up. 

Management of younger patients with advanced posttraumatic arthritis is a difficult dilemma. Celli and Morrey [41] reported a series of 55 elbow arthroplasties performed in patients aged less than 40 years with a mean 7.5-year follow-up. Thirty-six patients (65%) were considered to be excellent and fifteen (27%) were good.

Similarly, Park et al [42] reported a series of 23 elbow arthroplasties  performed in patients aged less than 40 years with a mean follow-up of 10 years. They reported favorable outcomes but 25% of elbows developed complications, with 22% requiring reoperation.

Primary OA

The elbow is not a weight-bearing joint, hence, the incidence of primary OA is rarer than that in other joints. The incidence is higher in individuals who overuse the upper extremities as in manual laborers, throwing athletes, and wheelchair-assisted individuals. Patients with primary OA usually have higher functional demands and capabilities than those with inflammatory arthritis [43]. Therefore it is critical to communicate with the patient regarding postoperative management, and the surgeon must stress that the risk of complications could increase if the patient continues to have the same habitual pattern of elbow use after the surgery. 

Schoch et al [44] reported the outcome of 18 elbow replacements for primary OA at a mean follow-up of 8.9 years (range, 2-20 years). Three elbows sustained mechanical failures. Fifteen elbows without mechanical failure were examined. Pain improved from 3.6 to 1.5. The range of motion remained clinically unchanged, with preoperative flexion contractures not improving. The Mayo Elbow Performance Scores were available for 13 elbows without mechanical failure, averaging 81.5 points (range, 60-100 points). Complications occurred in seven elbows, but the incidence of mechanical failure was low.

Complications of elbow arthroplasty

The significant complication rate following elbow arthroplasty ranges from 20% to 45%. It is very much higher than the complication rate associated with other major joint replacements [45,46]. 

Gschwend et al [47] in 1996 published a review of the world literature from 1986–1992, in which they analyzed 22 publications reporting 828 cases of elbow arthroplasty. They found an overall complication rate of 43%. These included aseptic loosening, dislocation, subluxation, infections, ulnar nerve complications, disassembly, intraoperative fractures, instability, mechanical failure of prosthetic components, and ectopic bone formation.

Voloshin et al [46] in 2011 noted that despite advances in prosthetic design and surgical technique for elbow arthroplasty over the previous decade, there had been no further systematic review of the literature reporting the complications of elbow arthroplasty since the mid-1990s. They noted that the rates of clinically significant loosening were similar between linked and unlinked designs. They found that the instability rate associated with unlinked devices was significantly greater than with linked implants. Bushing wear and disassembly is more often seen with linked implants.  

In 2015, Plaschke et al [48] reported a retrospective case-controlled study of 167 elbow arthroplasties carried out between 1980 and 2008.  They also did not find any difference in the results between linked and unlinked elbow arthroplasties. They stated that revision elbow arthroplasty is complicated surgery, that yields acceptable but poorer results than after primary elbow arthroplasty.

In 2018, Pham et al [49] reported their results using the Coonrad-Morrey elbow arthroplasty in 46 rheumatoid patients (54 elbows) between 1997 and 2012 with an average follow-up of 7 years (range 2–16 years). They found bushing wear in 16 elbows (29%), and there were 14 complications (26%). Revision surgery was necessary in 7 (13%). They concluded that the results were satisfactory but the rate of complications was high although the rate of implant revision remained low.

Infection, periprosthetic fracture, and aseptic loosening, are the most concerning common complications primarily requiring revision surgery.

Periprosthetic Joint Infection

Despite the use of modern surgical techniques and antibiotic prophylaxis, infection remains one of the leading complications of elbow arthroplasty. The reported rates range from 1% to 12.5% [25,50-53]. Few studies have evaluated the management of elbow periprosthetic infection after elbow arthroplasty because of its rarity. The elbow is susceptible to infection owing to the lack of soft-tissue covering from skin to bone [51,54-57].

Great care has to be taken to prevent infection. There has to be proper patient selection and aseptic surgical conditioning. In the patient selection stage, the surgeon must be aware of the risk of high comorbidity with diabetes [56,58-61]. There are several studies that have reported a a strong correlation between infection and comorbidity in patients with elbow arthroplasty [50,51,56,62,63].

Although there is no fully established consensus, two-stage revision surgery is commonly recommended for periprosthetic infection [63-65]. Zmistowski et al [66] reported that two-stage revisions led to a decreased rate of recurrent infection and a 50% success rate over 3 years. They recommended a prosthesis-free interval of at least 3 months. The most common pathogen causing the infection was Staphylococcus aureus [50,

53,54,55,57].

Aseptic Loosening 

Aseptic loosening of the elbow arthroplasty is one of the most common causes of revision surgery [14,15,16, 24]. 

In patients with elbow arthroplasty, the transmission of nonanatomic force results in stress shielding at the humeral condyles and olecranon, leading to progressive bone resorption. This bone resorption results in an increase of force on the arm between the hinge and the site where the stem transfers most of its load. This not only predisposes to loosening of the stem but also increases the likelihood of arthroplasty failure due to polyethylene wear, mechanical failure, or periprosthetic fracture [11,67,68,69,70].

Loose stems are amenable to revision elbow arthroplasty by using a longer stem, with bone grafting if indicated [67,68, 70].

King et al [71] reported a series of 31 patients who underwent revision elbow arthroplasty due to aseptic loosening with a mean follow-up of 6 years. The mean MEPS was 87, and the mean flexion-extension arc was more than 100°.

Triceps Insufficiency

Triceps insufficiency can occur after a failed surgical reattachment, especially when the tendon quality is poor or a traumatic rupture of the tendon is present. The rate of triceps insufficiently varies between 0.4% and 2.4% after elbow arthroplasty using various triceps-detaching approaches [72,73]. To reduce the risk of postoperative triceps weakness and rupture, a triceps-sparing approach is usually used for primary elbow arthroplasty. 

Several studies suggest that a triceps-sparing approach for primary elbow arthroplasty leads to fewer postoperative triceps ruptures as well as a better postoperative range of motion and extension torque [24,73].

Dachs et al [74] compared the triceps-sparing and triceps-detaching approaches for primary elbow arthroplasty. The rate of postoperative triceps rupture was 15.2% in the triceps-detaching group but there was no rupture in the triceps-sparing group. 

Solarz et al [75] compared the triceps-detaching with the triceps-sparing approaches and they reported that functional strength and Disabilities of the Arm, Shoulder, and Hand scores were significantly higher in the triceps-sparing group. The arc of motion, visual analog scale, and MEPS were similar between the two groups.

Periprosthetic Fracture

The third most common cause of elbow arthroplasty failure is periprosthetic fracture and it can pose difficulty for revision [76]. Since the upper extremity has smaller bones with less bone stock, management of bone defects is very important. Inadequate bone stock is the usually encountered problem, especially in patients with osteoporosis. Cortical strut allograft augmentation is required for revision in patients with poor or weak bone stock. A study by Sanchez-Sotelo et al [77] has reported that periprosthetic humeral fractures associated with a loose humeral component can be effectively treated with strut allograft augmentation and revision elbow arthroplasty. 

Bushing Wear

Multimodal wear in total elbow replacements can lead to osteolysis, aseptic loosening, and prosthetic and periprosthetic fracture that would require revision surgery [68]. Polyethylene wear and damage, as well as metal on metal wear, contribute to the periprosthetic particulates, which is pathogenic in these processes. 

Lee et al [78] suggested that one of the reasons for a component stem fracture after elbow arthroplasty seems to be fatigue failure at or near the junction between an unsupported stem and a well-fixed stem. Osteolysis caused by bushing wear leads to the stem being unsupported.

Other Complications

Other serious complications after elbow arthroplasty include:

• Wound breakage especially around the olecranon. 

• Ulnar nerve lesions are a significant complication after elbow arthroplasty, with potentially debilitating consequences. 

Surgical approaches for elbow arthroplasty

There are many surgical approaches to the elbow, of which the posterior approach is the most common.  It provides excellent access to the elbow and it is the approach that is most commonly used for total elbow arthroplasty [79-82]. In the posterior approach, the triceps is either split or reflected or the olecranon is divided.

Osteotomy of the olecranon is particularly valuable in the treatment of comminuted distal humerus fractures involving the articular surface. It is, however, not suitable for total elbow arthroplasty because an intact ulna is required for the fixation of the distal component of the prosthesis.  Techniques in which the triceps is split or reflected can be used for total elbow arthroplasty, but they give a less satisfactory exposure of the distal humerus than can be achieved by an olecranon osteotomy. 

The majority of approaches to the elbow for elbow arthroplasty utilize a posterior midline skin incision with full-thickness flaps and early identification of the ulnar nerve. The nerve needs to be identified early and superficially decompressed [83]. Transposition is advocated when there is pre-existing nerve deficits or where the prosthesis affects the nerve's usual course [84]. The nerve should be left in its bed to maintain its blood supply. 

The approaches are broadly categorized into triceps-on and triceps-off. Triceps-on approaches maintain the triceps mechanism and its insertion on the ulna. Triceps off approaches involve some or all of the triceps being taken off its ulna insertion. The triceps-off group are subdivided into triceps turndown, triceps slitting, or triceps elevating. A triceps turndown involves cutting of the triceps tendon proximal to the ulna insertion. The triceps elevating approach elevates the triceps off the ulna subperiosteally. A triceps splitting approach divides the triceps tendon longitudinally along its length and through its insertion.

Most of the triceps splitting techniques are modifications of the midline triceps split with elevation of each half of the triceps off the posterior humerus and ulna [85]. 

The Shahane–Stanley posterior approach combines a split and reflection of the triceps [86]. After the triceps is split, 75% of the muscle is reflected laterally and 25% medially. The medial triceps is reflected to the medial side with dissection under the ulnar nerve but attachment to the olecranon is maintained. The lateral triceps is reflected sub-periostally off the olecranon along with the anconeus. Transosseous sutures through the olecranon are used to repair the triceps.

A midline triceps split with subperiosteal mobilization of the lateral triceps is done in the tricep split and snip. The medial portion is mobilized off the posterior humerus. If required a snip of the triceps tendon is made of the medial triceps portion 1 cm to 2 cm proximal to the ulna. At closure, a side-to-side repair, as well as an end-to-end repair is required [87].

The anconeus-triceps lateral flap approach [88] utilizes the Kocher interval on the lateral side between the anconeus and extensor carpi ulnaris, and a plane between the lateral triceps expansion and the true tendinous part of the triceps. The triangular flap is then elevated proximally off the ulna to allow exposure to the joint. The tendinous portion of the triceps on the medial side remains on the ulna with proximal elevation off the back of the humerus.

The triceps-on approach is also called the triceps preserving or triceps retaining approach. The triceps and triceps insertion is maintained in continuity with the olecranon. These can be divided into single and dual approaches. A single medial triceps-on approach involves releasing the ulnar nerve and retracting it anteriorly. The medial collateral ligament and capsule are excised along the ulna border of the humerus. Distally, the flexor carpi ulnaris is elevated from the ulna and proximally the triceps is elevated from the back of the humerus. This leaves the triceps intact and the elbow can be dislocated with pronation [89,90]. 

In the lateral extended Kocher approach a lateral incision is made and the triceps is elevated off the lateral ridge and distally the plane is between the anconeus and extensor carpi ulnaris [91].

The Alonso-Llames bilaterotricipital approach [92] was first described for supracondylar fractures in children but subsequently, it was modified for elbow arthroplasty. The triceps is elevated on each side off the intermuscular septum and posterior humerus. Distally two para-olecranon incisions are made. The ulnar nerve is mobilized with a cuff of triceps fascia and capsule to allow closure at the end of the procedure [93]. 

The elbow can be dislocated laterally and the ulna is maximally exposed for instrumentation by hyper-pronating the forearm. 

In patients with a stiff elbow, a medial capsulotomy and subperiosteal elevation of the origin of the radial collateral ligament is often needed to enable dislocation of the elbow by distraction and flexion of the joint. This provides a wide exposure of the articular surfaces. 

During closure, the intramuscular septum of the triceps is first repaired. 

Closure of the muscle envelope begins by suturing the detached edge of the anconeus to its insertion into the proximal ulna. The deep closure is completed by suturing the reflected triceps fascia to its cut edge. It is always important to isolate, decompress, and protect the ulnar nerve during elbow arthroplasty.

The incidence of ulna nerve paresis complicating elbow arthroplasty varies between 31%–65% [94,95]. 

Revision elbow arthroplasty

Types of elbow arthroplasty failure can be divided into 2 groups namely the infected and non-infected group, based on serologic markers, imaging, and

intraoperative histology [50,70,96,97]. Elbow arthroplasty failure due to infection is treated by a two-stage revision, where in the first stage the implants are removed and the infection treated. This is followed by reimplantation after the infection has been controlled [96,98,99,100]. 

The non-infected type is treated by a one-stage revision and addressing the mechanical problems at the implant-implant or the implant-bone interface [101,102,103,104,105,106,107]. 

During the single-stage revision surgery, if one of the components is stable, the type of implant that matches the original implant is chosen.

Single-Stage Revision Surgery for Non-Infectious Cases

After the joint has been exposed sharp subperiosteal release of the collateral ligaments from the medial and lateral epicondyles is carried out. The prosthesis components are meticulously removed avoiding further damage to the bones. As much of the cement as possible is removed from the medullary canal. Tightly adhered cement can be left behind if it does not interfere with the implantation of the revision stem. Bone loss is usually managed with either cement or by shortening of the humerus or ulna. If there are epicondyle fractures, Kirschner wires are used to temporarily fix the fragments before reimplanting the components. Cerclage wire is used for longitudinal fractures of the humerus or ulna. A longer component is preferred in all patients undergoing revision surgery [76,77,108].

Two-Stage Revision Surgery for Infectious Cases

The first stage of surgery for infected cases involves the removal of the prosthesis and all infected tissue including the synovial membrane. Samples of the infected tissue surrounding the implants and joint fluid are cultured. The bone canals are irrigated with chlorhexidine solution diluted with 0.9% sodium chloride. Antibiotic cement spacer (5 gm gentamicin, 1 gm vancomycin, and 1 gm ceftriaxone per 40 gm cement) is placed in the joint space. 

Based on sensitivity tests the patient is given intravenous antibiotics for more than 6 weeks until complete normalization of all serologic markers (including WBC, ESR, and CRP) has occurred [54,62,109]. 

The second stage of surgery centers on joint reconstruction with a new implant after the infection has been controlled. After removal of the antibiotic cement spacer, tissue samples are taken for follow-up sensitivity testing. 

Morrey et al [103] have proposed three specific reconstruction techniques using allograft-prosthetic composite (APC) to manage bone defects. 

• Type I reconstruction (intussusception type) involves intussusception of the APC into the host bone and is sometimes modified in a reverse fashion so that the upper portion of the host bone is inserted by using the lower portion of the femur shaft as the allograft when the host bone is too narrow for insertion of the allograft bone. 

• Type II reconstruction involves inserting the distal aspect of the stem into the host canal with a strut-like extension of the graft coadapted externally to the cortex while adapting a cortical strut graft.

• Type III reconstruction comprises side-to-side contact between the cortices of the APC and the host bone. Wiring is often added to enhance the contact area and promote stable fixation between the host bones and the APC.

Conclusions

Rheumatoid arthritis remains the most common indication for total elbow arthroplasty although the annual incidence of elbow arthroplasties performed for inflammatory arthritis is decreasing. The indications for elbow arthroplasty have expanded to include trauma-related problems such as  unreconstructable elbow fractures and posttraumatic osteoarthritis. The complication rates are high. Various efforts have been made in revision surgery, such as the development of devices with different designs and surgical techniques.

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