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Ulnohumeral Arthroplasty

Introduction Primary degenerative arthritis of the elbow is discussed in detail in Chapter 76 . Over the years the etiology has been clarified, and the treatment trend is early intervention with arthroscopic débridement (see Chapter 21 ). Later stages may need to be managed with some form of prosthetic replacement (see Chapters 87 and 95 ). Incidence and Etiology The existence of primary degenerative arthritis of…

Synovectomy of the Elbow

Introduction Rheumatoid arthritis affects 1% to 2% of the general population. Prior to the introduction of disease-modifying antirheumatic drugs (DMARDs), involvement of elbow was present in more than half of the patients with involvement of more than 10 years. Clinical management is discussed in Chapter 77 . While less commonly needed, the surgical treatment options include synovectomy, interposition arthroplasty, and total elbow replacement. In the appropriate…

Revision of Failed Total Elbow Arthroplasty With Osseous Deficiency: Humeral Replacement and Allograft Prosthetic Composite Reconstruction

Introduction This chapter deals with two final options to preserve some effective function of the extremity. Other revision replacement options are discussed in Chapter 106, Chapter 107, Chapter 108 . We continue to use reinsertion into the cement host; strut grafting for deficiency and fracture and impaction grafting. However, when none of these strategies is viable ( Fig. 109.1 ), there are two remaining options to…

Revision of Failed Total Elbow Arthroplasty With Osseous Deficiency: Impaction Grafting

Introduction As discussed in Chapter 106 , the most important consideration when planning a revision procedure is the status of bone. If osseous integrity is compromised, what are the extent and nature of this feature? Of the several expressions of osseous deficiency, a chronically loose stem produces cortical thinning and expansion for the length of the stem ( Fig. 108.1 ). If allowed to progress, this…

Revision Total Elbow Arthroplasty With Strut Augmentation

Not uncommonly, substantial bone loss is encountered at the time of revision elbow arthroplasty. A successful reconstruction in these circumstances requires bone loss management. Several bone augmentation techniques are available depending on the nature and extent of bone deficiency. They include impaction of cancellous bone in a contained bone defect (impaction grafting), use of a structural allograft to support the prosthesis (allograft-prosthetic composite), or use of…

Revision of Nonseptic Failed Total Elbow Arthroplasty With Osseous Integrity

Introduction In spite of improvement in designs and technique, prosthetic failure remains a problem that may be solved with relative ease or may require extensive reconstruction techniques. The more challenging problems involve periprosthetic fracture and osseous deficiency and are covered in detail in Chapter 107, Chapter 108, Chapter 109 . The general problems of reimplantation for failed elbow arthroplasty are placed in perspective of alternate salvage…

Instability After Unlinked Total Elbow Arthroplasty

Introduction The incidence of instability following an unlinked total elbow arthroplasty (TEA) has been reported to range from 0% to 13%. The concern about instability and the challenges in treatment have resulted in a trend for surgeons to use a linked implant when performing elbow arthroplasty. Many factors must be considered in assessing the cause and in preventing instability following elbow arthroplasty. These include the implant…

Isolated Polyethylene Wear and Elbow Replacement

Introduction With the increasingly established reliability and success of total elbow arthroplasty (TEA) over the last 2 decades, indications for the procedure have expanded from rheumatoid arthritis to include the full spectrum of traumatic conditions, including posttraumatic arthritis, distal humeral nonunion, chronic fracture–dislocations, instability, ankylosis, and acute, comminuted, intraarticular fractures in the elderly. TEA for the latter is the most common indication for total elbow replacement…

Periprosthetic Elbow Fractures

Introduction Periprosthetic elbow fractures are difficult conditions complicating an elbow arthroplasty. They may occur intraoperatively during primary or revision surgery or after high- or low-energy trauma or may represent an end-stage implant loosening and osteolytic periprosthetic disease. This wide spectrum of mechanisms of injury and underlying host conditions requires a specific evaluation sequence, a clear algorithm for treatment decision making, and often special surgical techniques for…

Triceps Insufficiency Following Total Elbow Arthroplasty

Introduction Triceps insufficiency can occur as a result of traumatic rupture of the tendon or, most commonly, following a failed surgical reattachment, particularly when there is poor tendon quality. As a complication following elbow replacement, this is becoming much more appreciated, especially when the infected elbow is being treated. There is little evidence in the literature regarding this complication as most patients do not have significant…

Treatment of the Infected Total Elbow Arthroplasty

Introduction Despite multiple improvements in total elbow arthroplasty design, infection continues to be a potentially catastrophic complication, with reported rates of 5% to 11%. a a References . The incidence of infection is higher on the 5% to 11% spectrum when one is dealing with revision arthroplasty and in patients with rheumatoid arthritis. In the past few decades the infection rates have decreased since the introduction…

Diagnosis of Deep Infection After Elbow Arthroplasty

Introduction Infection after total elbow arthroplasty (TEA) is a common and devastating complication, with rates from 0 to 14% in clinical series. a a References . Despite the increasing procedure volume of TEA, no clear guidelines exist for the diagnosis of periprosthetic joint infection (PJI) in the elbow. Increasing research attention to this topic in the last 5 years has provided better data for clinical decision…

Complications of Elbow Replacement Arthroplasty

Introduction Complications after total elbow arthroplasty (TEA) have been widely publicized and are well recognized. An explanation for the high incidence of complications rests on the fact that the elbow is a complex joint that is poorly covered by soft tissue, is intimately traversed by a major nerve, and is vulnerable to host-compromising conditions, such as rheumatoid arthritis and previously operated on posttraumatic arthritis. A recent…

The Fused Elbow

Introduction The ankylosed elbow occurs spontaneously after trauma or results from formal intent. In either instance, the functional outcome is generally not well tolerated since there is no “optimum” position for elbow fusion. A stiff elbow cannot move the hand in and out of space, and adjacent joints compensate poorly for loss of elbow motion ( Fig. 98.1 ; also see Chapter 3 ). For these…

Dysfunctional Instability

Introduction Normal upper-extremity function requires a stable and mobile elbow joint. The unique architecture of the articular surfaces and surrounding soft tissues confers stability to the elbow. An intact joint is required for motion, providing a fulcrum for the muscles crossing the elbow to exert their power. Disruption of the bony and/or soft tissue architecture of the elbow compromises the ability to position the hand in…

Total Elbow Arthroplasty for Primary Osteoarthritis

Introduction Primary osteoarthritis of the elbow as discussed in Chapter 76 is a relatively common condition historically linked to overuse of the joint over extended periods of time as in manual laborers or heavy weight lifters. Patients initially present with pain at the extremes of motion or note limitation of motion. Often, the primary complaint is loss of motion, especially extension; impingement pain comes secondarily. Frequently…

Posttraumatic Arthrosis

Introduction With the advent of immunomodulating disease agents for the treatment of inflammatory arthritis, acute trauma and posttraumatic osteoarthritis have become more common indications for elbow arthroplasty. This distinct type of osteoarthritis may develop as a result of traumatic cartilage damage, joint incongruence of malreduced intraarticular fractures, or chronically subluxed or unstable elbows. Posttraumatic osteoarthritis differs from conventional osteoarthritis in several aspects and, in many ways,…

Total Elbow Arthroplasty for Distal Humeral Nonunion

Introduction Distal humeral nonunions occur frequently secondary to suboptimal fracture fixation in a comminuted fracture setting. Host factors such as smoking, osteoporosis, compromised soft tissue envelope, and noncompliance can also increase the chances of developing nonunion. Nonunion usually occurs at the supracondylar level secondary to limited cancellous bone and comminution at this level. The elbow joint is usually stiff; therefore most of the motion occurs from…

Distal Humeral Fractures

Introduction Distal humeral fractures are infrequent, when compared to other fractures and comprise approximately 1% to 2% of all adult fractures and 10% of humeral fractures. The population distribution of such fractures tends to be bimodal, with a peak in the 2nd and 3rd decades and a second peak in the 6th to 8th decades. The topic is variably covered in Chapter 44, Chapter 45, Chapter…

Elbow Arthroplasty in Inflammatory Arthritis

Introduction Elbow arthroplasty was first developed for patients with end-stage articular destruction secondary to inflammatory arthropathy, mostly rheumatoid arthritis (RA). In fact, the long-term performance of elbow arthroplasty has mostly been tested in inflammatory conditions. However, the pharmacologic treatment of RA has improved substantially over the last two decades. As a result, the number of patients with inflammatory conditions that eventually require an elbow arthroplasty seems…