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    Total Elbow Arthroplasty for Rheumatoid Arthritis

    A 77-year-old female presents with long-standing right elbow pain caused by rheumatoid arthritis. She has taken disease-modifying anti-rheumatic drugs and has had a corticosteroid injection without relief. The authors recommend total elbow arthroplasty to get her back to the gardening she loves.

    Authors

    Brian Lee, MD, and Matthew L. Ramsey, MD

    Disclosures

    Brian Lee, MD, has no disclosures relevant to this article. Matthew L. Ramsey, MD, receives royalties and consulting fees from Zimmer.

    Case Presentation

    A 77-year-old, right hand-dominant female presents for evaluation of long-standing right elbow pain caused by rheumatoid arthritis. The pain is consistent throughout the day and results in limited range of motion and inability to perform daily activities.

    She has taken disease-modifying anti-rheumatic drugs (DMARDs) without relief.Previously, the patient had a corticosteroid injection into the right elbow that did not provide lasting relief. She wants to return to gardening and indoor activities without heavy lifting.

    History and Physical Examination

    • Past medical history: Rheumatoid arthritis, hypothyroidism
    • Past surgical history: Left total shoulder arthroplasty
    • Social history: No tobacco use, retired
    • Right elbow examination
      • Range of motion 35° to 110°
      • Crepitus with range of motion
      • Pain through midrange of motion and at end ranges of flexion and extension
      • No gross instability
      • 5/5 strength with flexion and extension
      • No pain with palpation of extensor or flexor pronator mass
      • Non-subluxing ulnar nerve; no Tinel’s sign at the cubital tunnel
      • No rheumatoid nodules palpable

    Differential Diagnosis

    • Rheumatoid arthritis
    • Seronegative inflammatory arthritis
    • Osteoarthritis
    • Loose bodies
    • Fracture
    • Septic arthritis

    Imaging

    Anteroposterior, oblique, and lateral views of right elbow were ordered (Figure 1). The x-rays showed:

    • Severe degradation of joint cartilage with resorption of the trochlear subchondral bone
    • No spontaneous fracture
    • No evidence of ankylosis  

    Figure 1. AP, oblique, and lateral views of the right elbow.

    Diagnosis

    • Stage IIIA rheumatoid arthritis of the right elbow (Table 1)

    Table 1. Mayo Classification for Rheumatoid Arthritis

    Treatment

    Given that the patient had failed an extensive course of non-operative treatment and continued to experience severely debilitating pain, the authors recommended a right total elbow arthroplasty performed utilizing a para-olecranon triceps-sparing approach. [1]

    The literature on total elbow arthroplasty shows consistent results with regard to pain relief and function in this patient population, with up to 92% survival at 10 to 12 years postoperatively. [4]

    Advantages of total elbow arthroplasty include:

    • Improves pain and elbow function when compared with synovectomy
    • Preserves triceps insertion on the olecranon, facilitating early rehabilitation postoperatively
      • Triceps-detaching approaches have been associated with higher rates of triceps insufficiency/rupture [2,3]

    Total elbow arthroplasty is, however, a technically demanding surgery. Disadvantages include the following:

    • Increases complication rates when compared with synovectomy
    • Prolongs rehabilitation compared with synovectomy
    • Restricts patients to carrying no more than 5 pounds
    • Requires ulnar nerve transposition, which can cause pain in anterior subcutaneous position

    The authors prefer a semi-constrained linked implant for total elbow arthroplasty. This implant provides stability through the coupling mechanism. It also allows a few degrees of varus-valgus and rotational laxity to reduce stress on the bone-cement interface. Improved survivorship has been demonstrated when compared with unlinked designs. [5]

    There are, however, increased rates of radiographic loosening when compared with unlinked elbow arthroplasty implants, [6] in addition to a theoretical increased risk of aseptic loosening.

    Procedure

    • Supine position, non-sterile tourniquet applied
    • Posterior midline skin incision
    • Subcutaneous flaps elevated medially and laterally
    • Ulnar nerve identified proximally on the medial aspect of the triceps, dissected from the arcade of Struthers distally through the first motor branch to the flexor carpi ulnaris 
    • Nerve transposed anteriorly in the subcutaneous pocket
    • Laterally, interval developed between the subcutaneous border of the ulna and the anconeus
    • Dissection carried proximally, separating the portion of the triceps lateral to the insertion on the olecranon from the portion in continuity with the anconeus
    • Triceps tendon insertion onto the olecranon tip maintained. 
    • Common extensors and anterior capsule released with collateral ligament
    • Posterolateral capsule excised
    • Medial border of the triceps is developed to the olecranon attachment and separated from the posteromedial joint capsule
    • Posteromedial capsule and posterior fat pad debrided to facilitate exposure
    • Flexor carpi ulnaris and flexor pronator mass released from the medial epicondyle; anterior capsule released

    Humeral Preparation

    • Humerus delivered through the lateral triceps window
    • Central portion of the trochlea removed; intramedullary canal opened with a burr
    • Sequential rasping to prepare intramedullary canal
    • Bell saw used to create initial trephine cut with intramedullary rasp in place; cutting guide then utilized to make vertical medial and lateral cuts
    • Rasp removed and trephine stabilizer applied to the humerus anteriorly, protecting the soft tissues
    • Bell saw used to complete cut
    • Size 4 x 100 mm humeral component inserted and noted to fit into the prepared surface of the humerus

    Ulna Preparation

    • Tip of olecranon removed
    • Intramedullary canal entered with burr and sequentially reamed
    • Sequential rasping of ulna
    • Trial components placed, articulated, and taken through range of motion

    Component Implantation

    • Cement restrictors placed in the ulna and humerus
    • Antibiotic-impregnated cement injected retrograde into the canals
    • Components placed to final depths into humerus and ulna
    • Ulnar bushings assembled and articulated with the humeral component
    • Locking screws applied posteriorly to complete linkage
    • Bone autograft placed between humeral stem and anterior flange
    • Ulnar nerve positioned anteriorly
    • Elbow irrigated and closed in layered fashion; drain placed subcutaneously, exiting laterally
    • Elbow splinted in near extension with a well-padded anterior based splint

    Postoperative Course

    Immediate Postop Course

    The patient tolerated the procedure well, without complications. She was discharged home in a removable orthoplast splint on POD1, after the drain was removed. She was instructed to be non-weight-bearing and encouraged to continue hand range-of-motion exercises.

    Patient Progress

    Initial 10-day postoperative visit

    • Incision well healed, elbow range of motion 10° to 120° with full pronation; supination to 55°
    • Motor and sensory exam normal
    • Staples removed
    • Initiate physical therapy for gentle range of motion
    • X-rays show well-positioned humeral and ulnar components (Figure 2)

    Figure 2. 10-day postoperative images of the elbow.

    6-week postoperative visit

    • Improving with regard to pain relief, range of motion, and strength
    • Elbow range of motion 5° to 125°, full pronation and full supination
    • Physical therapy continues

    12-weeks postoperative visit

    • Continues to improve; elbow range of motion 5° to 135° with full pronation and supination
    • Excellent strength against resisted flexion and extension
    • X-rays show well-maintained humeral and ulnar components; bone-cement and cement-implant interfaces maintained; anterior flange bone graft incorporated (Figure 3)
    • Home exercises continue

    Figure 3. 12-week postoperative images of the right elbow.

    Author Information

    Brian Lee, MD, and Matthew L. Ramsey, MD, are from The Rothman Institute, Philadelphia, Pennsylvania.

    Shoulder Reconstruction Section Editor, Rothman Institute Grand Rounds

    Luke S. Austin, MD

    References

    1. Studer A, Athwal GS, MacDermid JC, Faber KJ, King GJ.  The lateral para-olecranon approach for total elbow arthroplasty.  J Hand Surg 2013;38A:2219-2226. 
    2. Hildebrand KA, Patterson SD, Regan WD, MacDermid JC, King GJ. Functional outcome of semi constrained total elbow arthroplasty. J Bone Joint Surg 2000;82:1379-1386.
    3. Inglis AE, Pellicci PM. Total elbow replacement. J Bone Joint Surg 1980;62:1252-1258.
    4. Gill DR, Morrey BF.  The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis: a ten to fifteen-year follow-up study.  J Bone Joint Surg 1998;80:1327-1335.
    5. Little CP, Graham AJ, Karatzas G, Woods DA, Carr AJ. Outcomes of total elbow arthroplasty for rheumatoid arthritis: comparative study of three implants. J Bone Joint Surg 2005; 87:2439-2448.
    6. Voloshin I, Schippert DW, Kakar S, Kaye EK, Morrey BF. Complications of total elbow replacement: a systematic review. J Shoulder Elbow Surg 2011;20:158-168.