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Total elbow arthroplasty

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Total elbow arthroplasty

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Total elbow arthroplasty

  1. 1. TOTAL ELBOW ARTHROPLASTY PRESENTER : Dr.SUDHEER KUMAR MODERATOR : Prof.Dr.BIJU RAVINDRAN
  2. 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. 3. GOAL OF TOTAL ELBOW ARTHROPLASTY Restore functional mechanics of elbow  Relief of pain  Restoration of motion  Stability
  4. 4. IMPLANT TYPES • Depending on rigidity of fixation of humeral component to ulnar component • FULLY CONSTRAINED • SEMI CONSTRAINED • UNCONSTRAINED
  5. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.
  15. 15. 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
  16. 16. • 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.
  17. 17. 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.
  18. 18.  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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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.
  24. 24. 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.
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. • 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
  29. 29. 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.
  30. 30. 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
  31. 31. Marked loosening of humeral stem with migration antero-laterally beyond the humeral cortex.
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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).
  36. 36. 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
  37. 37. • 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
  38. 38. 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.
  39. 39. Mayo classification of periprosthetic fractures after elbow arthroplasty

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