elbow arthroplasty in traumatology frédéric schuind, wissam el kazzi université libre de...

ELBOW ARTHROPLASTYIN TRAUMATOLOGY

Frédéric Schuind, Wissam El Kazzi

Université libre de Bruxelles,

Brussels, Belgium

Importance of elbow mobility and stability for upper extremity function

Elbow arthroplasty in traumatology

Loss of 50% of elbow function = loss of 80% of upper extremity global function (Sjöberg et al, 1996)

Elbow arthroplasty in traumatology

• Goals after a fracture :– To regain, as quickly as possible, full painless motion,

joint stability and strength– Pain ?

Elbow arthroplasty in traumatology

• Goals after a fracture :– To regain, as quickly as possible, full painless motion

and joint stability– Pain ?– Full motion ?

Elbow arthroplasty in traumatology

• Functional arcs of motion :– Most activities of daily life* :

• Arc of flexion-extension : 100° (30 to 130°)

• Arc of pronation-supination : 100° (50° pronation, 50° supination)

• Provided that other joints (especially the shoulder) are preserved for compensations

* Not considering specific professional or recreational/sportive demands

Elbow arthroplasty in traumatology

• Total elbow arthroplasty :– Main indication : rheumatoid arthritis– Types of implant :

• semi-constrained prostheses (Coonrad Morrey, GSB, …)

• resurfacing prostheses (Kudo, Souter-Strathclyde, …)

Internet

Elbow arthroplasty in traumatology

• Resurfacing implants of total elbow arthroplasty :

Sorbie-Questor unlinked TEA

Elbow arthroplasty in traumatology

• Complications of unlinked TEA designs :– Instability (rate of dislocation in rheumatoid arthritis

patients : 2 to 15 % - Ewald et al, 1993 ; Ruth et al, 1992 ; Trancik et al,

1987 ; van der Lugt et al, 2004 ; Weiland et al, 1989)– Loosening occurs

also (Pöll et al, 1991 ; Rozing, 2000; Valstar et al, 2002 ; van der Lugt et al,

2004)

Valstar et al, 2002

Elbow arthroplasty in traumatology

• Semi-constrained Coonrad-Morrey total elbow arthroplasty :– Type I (Coonrad prosthesis, 1973-1978):

• Titanium implant

• Simple hinge

• Unacceptable rate of loosening (17%)

– Type II (1979-1981)• Semi-constrained implant : built-in laxity in

– varus-valgus (7-10°)

– rotation (7°)

Elbow arthroplasty in traumatology

• Semi-constrained Coonrad-Morrey total elbow arthroplasty :

Elbow arthroplasty in traumatology

• Semi-constrained Coonrad-Morrey total elbow arthroplasty :

Motion under muscle stabilization

Elbow arthroplasty in traumatology

• Semi-constrained Coonrad-Morrey total elbow arthroplasty :– Type III :

• Anterior flange + bone graft to prevent posterio-superior migration of the implant

• Surface treatment by vaporized Titanium

Elbow arthroplasty in traumatology

• Semi-constrained Coonrad-Morrey total elbow arthroplasty :– Further evolutions :

• 1985 : Titanium beads in place of vaporized Titanium

• 1993 : Chrome-Cobalt instead of Titanium

Elbow arthroplasty in traumatology

• Latitude total elbow arthroplasty :– Allowing hemiarthroplasty if indicated

From Levine WN (Internet)

Elbow arthroplasty in traumatology

• Results of Coonrad-Morrey total elbow arthroplasty in rheumatoid arthritis :– Gill and Morrey, 1998

• 69 patients, 78 Coonrad-Morrey TEA’s with over 10 years

• Prosthesis survival rate 92.4%, with 86% good or excellent results (results almost comparable to THA)

Elbow arthroplasty in traumatology

• Results of Coonrad-Morrey total elbow arthroplasty in rheumatoid arthritis :– Little et al, 2005

• Comparative study of 33 Souter-Strathclyde, 33 Kudo and 33 Coonrad-Morrey TEA’s for rheumatoid arthritis

• Similar results in terms of pain relief (+ +), functional improvement (moderate), but better survival after Coonrad- Morrey (less dislocations)

Elbow arthroplasty in traumatology

• Norwegian Arthroplasty Register (562 prostheses) :– Bjorg-Tilde et al, 2009

• Various implants, only one Coonrad Morrey

• Overall failure rate :– 5 years 5%

– 10 years 15%

• Better results in patients with inflammatory arthritis

Bjorg-Tilde et al, 2009

Elbow arthroplasty in traumatology• Distal humerus fractures :

– 1 to 2% of adult fractures– Severe lesions :

• Most fractures are intraarticular and displaced

• AO classification

Elbow arthroplasty in traumatology

• AO classification of distal humerus fractures

Elbow arthroplasty in traumatology• Distal humerus fractures :

– The classical treatment includes open anatomical reduction (usually by posterior approach with olecranon osteotomy), internal fixation (classically rigid fixation to both medial and lateral columns), and early motion

– Frequent complications (up to 35% - ulnar neuropathy, elbow stiffness, nonunion, heterotopic ossifications)

Elbow arthroplasty in traumatology

• Comminuted fractures of the distal humerus in the elderly patient :– Comminuted fractures … or fractures not amenable to

stable fixation because of • severe osteoporosis

• prior joint disease (rheumatoid arthritis)

– Very bad results of internal fixation in such patients ( > 50 y.o. - Pajarinen et al, 2002)

– Better solution : immediate linked arthroplasty (with removal of fracture fragments – “working space”, allowing preservation of triceps continuity) ?

Elbow arthroplasty in traumatology

• Comminuted fractures of the distal humerus in the elderly patient :

Elbow arthroplasty in traumatology– Young patients : all possible efforts to achieve

anatomical reduction, stable fixation and immediate motion

– Patients over 65 y.o. : osteosynthesis or TEA ?• Osteoporosis

• Fracture comminution

• Comorbidities

• Compliance with postoperative physiotherapy

Elbow arthroplasty in traumatology– Cobb et al (1997), 21 TEA’s after fracture (10 with

concomitant rheumatoid arthritis, 3 after failed attempt at internal fixation) :

• Mean age of 72 y.o. (48 to 92)

• Mean interval fracture-arthroplasty : 7 days (1 to 25)

• Mean follow-up : 3.3 years (3 months to 10.5 years)

• 15 excellent, 5 good results, no loosening

• 1 fracture of the ulnar component following a fall

• 3 neurapraxiae of the ulnar nerve, 1 algodystrophy

• Better results than osteosynthesis ?

Elbow arthroplasty in traumatology

• Gambirasio et al (2001)– Prospective study of 10 osteoporotic fractures in elderly

patients (mean age 84.6)– Cemented Coonrad Morrey total elbow arthroplasty– Mean joint motion amplitudes : 125-23.5-0°– Mean Mayo elbow score : 94 (80-100)– One patient developed mild heterotopic ossifications

Elbow arthroplasty in traumatology

• Discussion, elbow fracture and TEA (5) :– Frankle et al, 2003, 24 patients > 65 y.o., 12 cases of

osteosynthesis, 12 of TEA (8 with rheumatoid arthritis) :• All fractures C2 or C3

• Mean follow-up : 57 months (24 to 78)

• Evaluation : Mayo Clinic Elbow score

• Osteosynthesis:– 10/12 olecranon osteotomy

– 4 excellent, 4 good, 1 fair and 3 bad results (all 3 > TEA)

– 1 infection, 3 secondary displacements > TEA

• TEA :– 11 excellent and 1 good results

– complications : 2 transient sensory lesions of the ulnar nerve, 1 superficial infection, 1 hematoma, 1 implant fracture

Elbow arthroplasty in traumatology

• Discussion, elbow fracture and TEA (6) :– Obremskey et al, 2003, meta-analysis 1969 – 2003 :

• All articles level V (E.B.M)

• Better functional results after TEA (90%) than after osteosynthesis (75-85%)

• Main complications of TEA : loosening and infection (Yamaguchi et al, 1998 : rate of infection 1-12%)

• Short follow-up (< 4 years) > no definitive conclusion concerning the long-term results after TEA

• Experience and judgment of the surgeon !

Elbow arthroplasty in traumatology

• Discussion, elbow fracture and TEA (7) :– SOFCOT series (Charissoux et al, 2008) :

• 238 comminuted intra-articular fractures in aged patients

• 172 ORIF (younger patients), 44 TEA

• Results tend to be better with less complications after TEA

• Recommendations :

Elbow arthroplasty in traumatology

• Comminuted fractures of the distal humerus in the elderly patient :– McKee et al, 2009 :

• Prospective, randomized study comparing 21 ORIF and 21 TEA in elderly patients

• Five intraoperative conversions ORIF TEA

• Operative time less in TEA group

Elbow arthroplasty in traumatology• Comminuted fractures of the distal humerus in the

elderly patient :– McKee et al, 2009 :

• Better functional results in TEA group at 2 years (joint motion amplitudes, Mayo Elbow Score and DASH – but only at 3 and 6

months)

Elbow arthroplasty in traumatology

• Comminuted fractures of the distal humerus in the elderly patient :– McKee et al, 2009 :

• Non-significant difference regarding reoperation rate (TEA 12%, ORIF 27%)

• Conclusion : TEA is the preferred alternative for complex distal humerus fractures non amenable to stable fixation in elderly patients

Elbow arthroplasty in traumatology

• Clinical example :– 68 y.o. left-handed woman– C3 comminuted, closed fracture of left distal humerus

after a simple fall

Elbow arthroplasty in traumatology

• Clinical example :

Elbow arthroplasty in traumatology

• Clinical example, 14th postoperative months X-rays :

Elbow arthroplasty in traumatology

• Clinical example, 21st postoperative month :– Flexion-extension : 140°-45°-0°– Pronation-supination : 90°-0°-75°– Mayo Clinic Elbow score : 80/100 (good)– Pain : VAS 6/10

Elbow arthroplasty in traumatology

• Second example :– 60 y.o. female interpreter– Closed comminuted fracture of left trochlea and

capitulum (C3)

– Coonrad Morrey TEA

Elbow arthroplasty in traumatology

• Second example :– 13 months

postop : no pain, flexion extension 140-15-0°, pronation supination 90-0-90°, excellent elbow extension strength

– Advice to be careful !

• Third clinical example, comminuted fracture of proximal ulna with associated radial head dislocation in a polytrauma patient (including associated cerebral lesions)

Elbow arthroplasty in traumatology

Elbow arthroplasty in traumatology

• Third clinical example :– External fixation > insufficient reduction, persistence of

radial head dislocation– Internal fixation, insufficient stability, re-dislocation– New external fixation, re-dislocation

Elbow arthroplasty in traumatology

• Third clinical example :– Coonrad-Morrey TEA

Elbow arthroplasty in traumatology

• Third clinical example, 16th postoperative month :– Flexion-extension : 125°-20°-0°– Pronation-supination : 30°-0°-30°– Mild pain– Mayo Clinic Elbow score :

73/100, DASH 96/150– Ulnar nonunion, no loosening

Elbow arthroplasty in traumatology

• Third example – 71 months after the operation :– Flexion-extension 120°-65°-0°, pronation-supination

80°-0°-50°– Pain : VAS 3/10– Mayo Clinic Elbow score : 80/100 (good)

Elbow arthroplasty in traumatology

• Conclusions (1) :– Good alternative in case of comminuted distal humeral

fracture not amenable to satisfactory osteosynthesis in osteoporotic aged patients

– Many complications, some quite serious (infection, loosening)

– Long term results ?

Elbow arthroplasty in traumatology

Elbow arthroplasty in traumatology

• Conclusions (2) :– Present indications given the recent development of

locked plates ?– Indications of unlinked arthroplasty (Kalogrianitis et al,

2008) ? of hemiarthroplasty ?

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