Total elbow replacement - patient selection and perspectives

Abstract

Total joint replacements for elbow arthritis were developed in the late 1960s at the same time as total joint replacements for knee joint arthritis. Since then, there has been a continuing annual increase in the number of patients treated with total knee joint replacement for arthritis, in line with replacement arthroplasty of the other major limb joints, but in contrast to total elbow joint replacement which is falling, since reaching a peak in the 1990s. Which raises the question, why? Continuing controversy about implant design, the relatively high reported complication rates associated with total elbow replacement (TER) and the difficulties encountered in revision surgery are identified as reasons together with changes in the patient population currently treated with TER. The purpose of this review is to explore the reasons for this in the context of the patient population requiring implant surgery for elbow arthritis and our current perspective of elbow pathology requiring treatment. This is not a systematic review of the whole of the literature concerning total elbow joint replacement arthroplasty but is drawn largely from the supporting literature that reflects my own clinical experience and illustrated with teaching materials I have commissioned together with radiographs and intraoperative photographs of patients I have treated.

Keywords: arthritis; arthroplasty; arthroscopy; elbow; fractures.

Figure 1

(A) Fully constrained uniaxial TER (Dee elbow): late 1960s. (B) Fully constrained uniaxial TKR (Walldius knee): same period. (C) Loosening of the components of a uniaxial TER (Stanmore elbow). Note the considerable bone loss around the humeral stem and perforation of the cortex, which would complicate a revision procedure. Abbreviations: TER, total elbow replacement; TKR, total knee replacement.

Figure 2

(A) Linked designs of TER. Left: Stanmore, right: Triaxial. (B) Unlinked design of TER. Left: Souter-Strathclyde, right: Kudo (type IV). Abbreviation: TER, total elbow replacement.

Figure 3

Examples of the wide range of designs of TER available in the 1980s when the design of TKR had become standardized. Notes: (A) Wadsworth: unlinked stemless components; (B) Wadsworth unlinked stemmed components; and (C) Triaxial: linked stemmed components. Abbreviations: TER, total elbow replacement; TKR, total knee replacement.

Figure 4

Complications of TER: aseptic loosening. Notes: (A) (Upper) Radiographs showing loose Souter-Strathclyde components and a photograph of the components removed during revision surgery. Revision surgery of this design of TER was facilitated by the relative short stem of each component. (B) (Lower) Radiographs showing loosening of the components of Coonrad-Morrey TERs. Left: the loose humeral stem of this TER has perforated the anterior bone cortex. Right: loosening of the ulnar component of this TER is further complicated by periprosthetic fracture. Revision surgery is more difficult because of the lengths of the component stems requiring removal. Abbreviation: TER, total elbow replacement.

Figure 5

Complications of TER: mechanical failure. Notes: (A) (Upper) Kudo (type IV) TER. Left: lateral radiograph. Right: photograph of the humeral component removed during revision. The stem of the humeral component was fractured at its junction with the barrel. This tendency was later solved by a design change. (B) (Lower) Coonrad-Morrey TER. Anteroposterior and lateral radiographs demonstrate that fracture of the stem of the humeral component has occurred. Removal of the sections of well-fixed component stems following mechanical failure is generally more difficult than removal of intact stems following component loosening. Abbreviation: TER, total elbow replacement.

Figure 6

Complications of TER: instability more commonly complicates unlinked designs of TER. Notes: (A) (Upper) Anteroposterior and lateral radiographs of a subluxated instrumented bone preserving TER. However, the tendency to bushing wear can result in disassembly of the components of a linked TER. (B) (Lower) Lateral radiographs of a triaxial TER. The radiograph on the left demonstrates disassembly of the components which necessitated revision. Abbreviation: TER, total elbow replacement.

Figure 7

A posterior surgical approach suitable for elbow arthroplasty. Notes: (A) The skin and subcutaneous tissues have been reflected to reveal the distal triceps designated “triceps tendon.” The ulnar nerve has been mobilized and decompressed. (B) A longitudinal incision through the deep fascia beginning proximally in the midline has been directed around the radial aspect of the tip of the olecranon ending at the subcutaneous border of the ulna. The fascia covering triceps and anconeus has been reflected exposing the muscular insertion of triceps. (C) Anconeus is detached from the subcutaneous border of the ulna together with lateral triceps from the tip of the olecranon. (D) Lateral triceps is separated from a longitudinally disposed intramuscular septum and retracted with anconeus exposing the radiocapitellar joint and lateral supracondylar ridge of the humerus. (E) The intermuscular septum is divided proximal to its insertion into the tip of the olecranon enabling triceps to be reflected to expose the olecranon fossa and medial supracondylar ridge. (F) Medial capsulotomy is performed and (G) subperiosteal elevation of the origin of the radial collateral ligament in stiff elbows. (H) Dislocation by distraction and flexion provides a wide exposure of the articular surfaces. (I) Soft tissue closure begins with repair of the intermuscular septum. (J) The remaining soft tissue envelope is then closed. Reproduced with permission from Pooley J. Unicompartmental elbow replacement: development of a lateral replacement (LRE) arthroplasty. “https://journals.lww.com/shoulderelbowsurgery/Abstract/2007/12000/Unicompartmental_Elbow_Replacement__Development_of.7.aspx” Techniques in Shoulder & Elbow Surgery. 2007;8:204–212.

Figure 8

Arthroscopic appearances of the left elbow of a 43-year-old male patient with severe elbow pain referred with a diagnosis of “resistant epicondylitis.” Notes: (A) There is full-thickness loss of the articular cartilage from the radiocapitellar joint surfaces (lateral compartment). (B) The articular cartilage of the ulnohumeral joint (medial compartment) appears normal.

Figure 9

(A) Intraoperative photograph during elbow arthrolysis on a 54-year-old male patient for pain and stiffness. Full-thickness loss of the articular cartilage in the radiocapitellar joint contrasts with the well-preserved articular surfaces of the ulnohumeral joint. (B) The preoperative radiographs demonstrate little evidence of degenerative change. Notes: Reproduced with permission from Pooley J. Unicompartmental elbow replacement: development of a lateral replacement (LRE) arthroplasty. “https://journals.lww.com/shoulderelbowsurgery/Abstract/2007/12000/Unicompartmental_Elbow_Replacement__Development_of.7.aspx” Techniques in Shoulder & Elbow Surgery. 2007;8:204–212.

Figure 10

(A) Anteroposterior radiograph demonstrating primary (hypotrophic) osteoarthritis with minimal osteophyte formation but marked narrowing of the radiocapitellar joint space. (B) Intraoperative photograph of this patient demonstrating the pattern of articular cartilage degeneration. The radiocapitellar joint surfaces are denuded of articular cartilage; the articular surfaces of the ulnohumeral joint, however, are well preserved. (C) An early postoperative radiograph following insertion of the components of a lateral resurfacing elbow. Notes: Reproduced with permission from Pooley J. Unicompartmental elbow replacement: development of a lateral replacement (LRE) arthroplasty. “https://journals.lww.com/shoulderelbowsurgery/Abstract/2007/12000/Unicompartmental_Elbow_Replacement__Development_of.7.aspx” Techniques in Shoulder & Elbow Surgery. 2007;8:204–212.

Figure 11

(A) Anteroposterior and lateral radiographs of an elbow demonstrating the characteristic appearances of primary (hypertrophic) osteoarthritis. Prominent osteophytes can be seen arising from the tip of the coronoid and olecranon, which has been interpreted as evidence of osteoarthritic change involving the ulnohumeral joint. (B) Left: intraoperative photograph of this patient demonstrating the degenerative changes (loss of articular cartilage) is confined to the radiocapitellar joint; the ulnohumeral joint surfaces are healthy. Middle: radial and capitellar components of an LRE. Right: intraoperative photograph following insertion of the LRE components. Abbreviation: LRE, lateral resurfacing elbow.

Figure 12

(A) Left: AP radiograph showing the characteristic appearances of rheumatoid disease involving the elbow before the development of effective disease-modifying drugs. The definition between the trochlea and the capitellum has been lost, and the radial head has subluxated laterally. The elbow joint has effectively become one-compartmental. Middle: intraoperative photograph of this patient demonstrating severe destruction of the joint surfaces. The radial head has been resected prior to the insertion of a TER. Right: postoperative radiograph following insertion of a TER (IBP), which is appropriate reconstruction for this pattern of joint disease. (B) Left: AP radiograph demonstrating the characteristic appearances of rheumatoid disease involving the elbow in a patient treated with disease-modifying drugs. There is loss of joint space (secondary osteoarthritis) but the normal bone architecture and the two-compartmental configuration of the elbow joint are preserved. Middle: intraoperative photograph of this patient. The radial head articular surface and much of the capitellum were denuded of articular cartilage; the ulnohumeral joint surfaces appeared degenerate but better preserved. Right: postoperative AP radiograph following insertion of a lateral resurfacing elbow, which relieved the preoperative symptoms. Notes: (A) Middle and left impages reproduced with permission from Pooley J. Unicompartmental elbow replacement: development of a lateral replacement (LRE) arthroplasty.“https://journals.lww.com/shoulderelbowsurgery/Abstract/2007/12000/Unicompartmental_Elbow_Replacement__Development_of.7.aspx” Techniques in Shoulder & Elbow Surgery. 2007;8:204–212. Abbreviations: AP, anteroposterior; IBP, instrumented bone preserving; TER, total elbow replacement.

Figure 13

(A) AP radiograph of an osteoarthritic elbow with a “congenital hole” between the olecranon and the coronoid fossae, similar to that which Outerbridge reported to Kashiwagi which led to the development of the Outerbridge–Kashiwagi procedure for the removal of olecranon and coronoid osteophytes (“ulnohumeral arthroplasty”). (B) Postoperative AP radiograph following arthrolysis which confirmed degenerative changes confined to the radiocapitellar joint surfaces; the ulnohumeral joint surfaces were well preserved – a lateral resurfacing elbow arthroplasty has been inserted. Abbreviation: AP, anteroposterior.