11/9/15. Total Elbow Arthroplasty. Who would not want this Patient? I have 3 hours of Free Time!!! KRISTOPHER R. AVANT, DO

Transcription

1 Total Elbow Arthroplasty KRISTOPHER R. AVANT, DO SOUTH W E ST ORTH OP A E DIC SP EC IALISTS BONE & JOINT HOSPITAL OKLAHOMA CITY, OK Who would not want this Patient? I have 3 hours of Free Time!!! 1

2 A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. Frankle MA1, Herscovici D Jr, DiPasquale TG, Vasey MB, Sanders RW. J Orthop Trauma Aug (ORIF) vs. (TEA) for intraarticular distal humerus fractures in women > women >65 with distal humerus fractures Follow-up at a minimum of 2 years All fra ctures were OTA 13.C2 or 13.C3 No patients lost to follow-up 12 with ORIF: 4 excellent, 4 good, 1 fair 3 poor (Required conversion to TEA) 12 with TEA: 11 excellent and 1 good No fair or poor outcomes in the TEA None treated with TEA required revision surgery Implant Types Fully Constrained Rarely used Metal-to-metal hinge Loosen and break frequently Semi-constrained Built-in varus/valgus laxity Unconstrained Require intact ligaments and capsule for stability Next play?? 2

3 Pre-op Planning Imaging Radiographs Humeral Canal Size & Bow Ulnar Canal Size & Angulation CT Infection Serology Elbow Aspiration / Culture (S. Epi) Physical Exam Soft tissue envelope Ulnar Nerve status Previous Op-notes Patient Position Supine with arm board Bump under scapula Lateral Prone (If you hate Anesthesia) X-ray visualization Adequate exposure Surgical assistants Surgeon preference Approach *Triceps Insufficiency Rates % reported in TEA literature* Triceps Splitting Ca mpbell Mayo Triceps Peel Postero-media l Brya n-morrey Triceps-Reflecting Anconeus Flap (TRAP) Triceps Posterior Reflecting VanGorder V-Y Triceps Hemi-peel Triceps-sparing (Para-tricipita l) Alonso-Lla mes Medial and Lateral Window Surgical Approach - Based on indication Primary TEA > Bryan Morrey TEA Fx > Triceps sparing Revision TEA > Triceps reflection or split 3

4 Implants (Semi-Constrained) Tornier Latitude Radiocapitellar Zimmer Nexel E-poly DJO Discovery Extramedullary vs. Intramedullary Humeral Guides Cannulated reamers Porous Coating Linkage Axis of Rotation Stem Sizes-Revision Humeral Preparation (Protect the Condyles!!) Expose Ulnar Nerve / Transpose Open medial articular window Mobilize Triceps Lateral window Release LCL / MCL Resect Trochlea (save for ant. flange) Strip Anterior Capsule Anterior Flange Bone Graft Resect Seat Rasp to Axis of Rotation(resect anteriorly) Don t forget about radial nerve Ulnar Preparation (Previous olecranon osteotomy?) Remove tip of olecranon Parallel to ulna Allow straight-line access to canal Take more than you think Use rongeur to notch Use burr to expose canal Flexible reamers for ulna Care to not perforate lateral and dorsal cortex Check for impingement - coronoid / sigmoid notch Address radial head as indicated (PIN) 4

5 Incomplete Extension Inadequate depth of insertion of the Humeral Component Inadequate depth of insertion of the Ulnar Component Unresolved angular deformity Inadequate release of anterior, medial or lateral softtissue contracture Posterior bone impingement Flexion Impingement Coronoid impingement on the anterior flange Remove bone as necessary to obtain adequate flexion Insertion of Implant Humeral and Ulnar components Separately Joined on back table / Fully Flexed Cement Restrictors +/- Antibiotic-Impregnated Cement Pre-coat stems? Appropriate Cement Tips 5

6 J Shoulder Elbow Surg May Fevang BT1, Lie SA, Havelin LI, Skredderstuen A, Furnes O. 562 total elbow replacements Report from the Norwegian Arthroplasty Register 562 TEA s (1994 and 2006) 5- and 10-year failure rates were 8% and 15%, respectively Post-traumatic arthritis after fracture had the worst prognosis compared with inflammatory arthritis Special Instruments = High Maintenance? Burr (3-4 mm/pinecone) Sawblade Cement restrictor and prep kit Footed Tamp Niece Loop Implant specific extractors Allograft Cerclage wires Ball tipped guidewires reamers Broken Screw Removal Set Depuy Moorland - Shoulder Post-op Care Elevation Elbow above shoulder Pillow/Hip Abduction Wedge/IV pole Drains Dressing Physical Therapy Avoid active elbow extension (3 months Triceps) Avoid strengthening exercises Long-term Restrictions 5 lbs. (1 st Three months) 10 lbs. (Forever!!) 6

7 Rating Outcomes Morrey (Radiographic Appearance Pain Motion) Painful or Failed TEA Instability Polyethylene Issues Osteolysis Aseptic Loosening Infection Fracture Heterotopic Ossification Ulnar Nerve Issues Wound / Soft Tissue Triceps Insufficiency Special Circumstances Humeral fixation with a concomitant shoulder arthroplasty Gill et al., the authors recommended filling IM canal with cement if the interval between the humeral component stems is less than 6 cm); 7

8 Future Improved Modularity Bone-loss specific implants Press-Fit Stems? Implant-Bone-Cement Interface Hemiarthroplasty Implants Thank You!!! 8