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Elbow Total Arthroplasty

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Topic updated on 06/16/15 8:44pm
Introduction
  • Forms of elbow arthroplasty include
    • elbow total arthroplasty
    • elbow partial arthroplasty 
      • ulnohumeral distraction & interpositional arthroplasty
      • olecranon fossa debridement
      • radial head arthroplasty
  • Designs 
    • unconstrained or unlinked
      • examples include Ewarld capitella
      • requires competent collateral ligaments and good bone quality as stability supplied by the soft tissue
      • resurfacing arthroplasty
      • instability is most common complication (5-10% dislocation)
    • semiconstrained or linked   
      • examples include Coonrad-Moorey
      • "sloppy hinge" allows for some varus and valgus motion
      • best results of all of the designs
      • complication of early loosening
    • constrained
      • increased loosening rates compared to semiconstrained devices
Indications
  • Indications  
    • rheumatoid arthritis (RA)
      • highest survivorship when done for RA  
      • reliable procedure for advanced, refractory RA
      • indications include pain, loss of motion, instability
      • Larsen stage 3 through 5
    • primary osteoarthritis (advanced)
      • patient should be >65 years old
    • posttraumatic osteoarthritis (advanced)
    • fracture
      • complex intraarticular fracture in patient > 70 years
    • chronic instability
  • Contraindications
    • absolute
      • active infection (arthrodesis favored)
      • Charcot joint
    • relative
      • poor neurologic control of affected extremity
      • active patient younger than <65 years old
      • olecranon osteotomy 
Technique
  • Surgical
    • approach 
      • triceps splitting or sparing posterior approach
      • usually perform ulnar transposition
      • radial head resection common
  • Postoperative care
    • early period of immobilization 
      • Early motion after TEA is associated with wound complications, instability, and hardware loosening
      • Typically immobilize for 4 weeks after surgery
    • lifelong weightlifting restriction of 10 lb
Outcomes
  • Rheumatoid arthritis TEA outcomes
    • 10 year survivorship
      • 92.4% rate of survivorship free of revision at 10 to 12 years
      • however very high complication rate (14%) 
        • triceps avulsion
        • deep infection
        • periprosthetic fracture
        • aseptic loosening
  • Post traumatic arthritis TEA outcomes
    • 5 year survivorship
      • most achieve functional ROM and patient satisfaction
      • high complication rate (27-43%)
      • high re-operation rate (25%)
Complications
  • Aseptic loosening (radiograhic 17%, clinical 6%)
  • Infection (8%)
    • acute infection (< 30 days)
      • treatment
        • aggressive serial irrigation and debridement and antibiotic bead placement
        • success depends on organism
          • staphylococcus epidermidis is associated with persistent infection because it is an encapsulating organism, and it is best treated with implant removal and IV antibiotic
    • chronic infection
      • treatment
        • two staged reimplantation versus resection arthroplasty in medically ill patients or those with inadequate bone stock. 
  • Instability (7-19%)
  • Bushing wear (obtain AP xrays and varus/valgus angle of > 10 degrees is concerning)
  • Wound healing (higher with longterm steroid use)
  • Ulnar neuropathy
  • Triceps insufficiency

 

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Qbank (7 Questions)

TAG
(OBQ12.40) A 62-year-old female with history of rheumatoid arthritis presents with end-stage elbow arthritis. Regarding total elbow arthroplasty (TEA) for rheumatoid arthritis, which of the following implant survival results would be expected? Topic Review Topic

1. Poor survival results by 5 years
2. Good survival results at 5 years, poor results by 10 years
3. Good survival results at 10 years, poor results by 15 years
4. Good survival results at 15 years
5. Lack of long-term survival studies regarding TEA for rheumatoid arthritis

PREFERRED RESPONSE ▶
TAG
(OBQ11.261) What is the preferred treatment for a propionibacterium acnes infection that has been symptomatic for 6 months after total elbow arthroplasty with well-fixed components, good bone stock, and a healthy patient? Topic Review Topic

1. Non-operative treatment with IV antibiotics for 6 weeks
2. Arthroscopic irrigation and debridement
3. Open irrigation and debridement with poly exchange
4. Single stage revision arthroplasty
5. Two stage revision arthroplasty

PREFERRED RESPONSE ▶
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