HISTORICAL PERSPECTIVE

Peter S. Johnston

Matthew L. Ramsey

 

 

Normal elbow function requires a pain-free, mobile, and stable articulation. Nonarthroplasty surgeries

 

Resection arthroplasty, interposition arthroplasty, and arthrodesis predominated prior to the advent of elbow arthroplasty.

 

ELBOW ARTHROPLASTY (HISTORY)

 

Development of total elbow arthroplasty (TEA) was borne out of the failures of nonreplacement surgeries to effectively treat articular and periarticular pathologies.

 

 

The elbow was felt to function as a rigid hinge. Early efforts at elbow arthroplasty

 

Characterized by metallic, nylon, rubber, or acrylic hemiarthroplasties of the distal humerus or proximal ulna (FIG 1).

 

TEAs were metallic rigid hinged devices.

 

 

Predated the introduction of polymethylmethacrylate (PMMA)

 

Fixation of these implants to bone was achieved through uncemented intramedullary stems or extramedullary supports screwed into cortical bone (FIG 2).

 

 

Instability, early loosening, and unpredictable range of motion limited the success of these implants.

 

Poor implant fixation to bone and inferior implant design contributed to high failure rates from early loosening.

 

EVOLUTION OF ARTHROPLASTY (EARLY EFFORTS)

 

The modern era of total elbow replacement was initiated with the introduction of PMMA for implant fixation.9

 

The period of time following this achievement was characterized by a rapid evolution in the understanding of elbow biomechanics and surgical techniques and improvements in implant materials and design.

 

 

A growing body of biomechanical and clinical data demonstrated that a simple hinge did not adequately replicate the mechanics of the elbow. Out-of-plane motion must be accounted for in implant design to prevent loosening.15,28

 

The failure of early efforts at arthroplasty led to two approaches to implant design.

 

 

Unlinked “resurfacing” designs

 

 

The joint is resurfaced with preservation of the collateral ligaments (FIG 3).

 

Success depends on the integrity of the soft tissue envelope, the presence of adequate bone stock to support the prosthesis, and the geometry of the articulation.

 

The contribution of the soft tissues to absorbing the forces across the elbow is believed to result in lower rates of implant loosening.

 

 

 

FIG 1 • A. Metallic resurfacing replacement of the proximal ulnar articular surface designed by Bickel and Peterson. B. Metallic distal humeral resurfacing replacement designed by Street and Stevens. Both implants were not stemmed and were poorly fixed to native bone. (A: From Peterson LFA, Jones JM. Surgery of the rheumatoid elbow. Orthop Clin North Am 1971;2:667; B: From Street DM, Stevens PA. A humeral replacement prosthesis for the elbow: results in ten elbows. J Bone Joint Surg Am 1974;56[6]:1147-1158.)

 

 

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FIG 2 • A. Photograph of a linked, fully constrained hinged replacement. B. Clinical radiograph of the implant used to treat massive bone loss. Note the extramedullary fixation of the implant to native bone with cerclage metallic straps. (From Cooney WP, Morrey BF. Elbow arthroplasty: historical perspective and emerging concepts. In: Morrey BF, Sanchez-Sotelo J, eds. The Elbow and Its Disorders. Philadelphia: Saunders Elsevier, 2009:705-719.)

 

 

Linked “semiconstrained” designs

 

 

Stability is achieved through a coupled articulation between the humeral and ulnar components which allows a few degrees of varus-valgus and rotational laxity (FIG 4).

 

The ulnohumeral articulation tracks within the tolerance of the implant implying that the muscular envelope counters some of the forces across the elbow.29

 

EVOLUTION OF ARTHROPLASTY (MODERN EFFORTS)

 

TEA is in a period of refinement.

 

Clinical experience has demonstrated the design features that are acknowledged to contribute to success.

 

 

Anterior flange

 

 

Incorporated into many linked humeral designs

 

Felt to counteract posterior and rotational forces across the elbow contributing to implant loosening

 

 

 

FIG 3 • A. The capitellocondylar resurfacing prosthesis. B. The Souter-Strathclyde resurfacing prosthesis. (From Cooney WP, Morrey BF. Elbow arthroplasty: historical perspective and emerging concepts. In: Morrey BF, Sanchez-Sotelo J, eds. The Elbow and Its Disorders. Philadelphia: Saunders Elsevier, 2009:705-719.)

 

 

Incorporation and hypertrophy of the bone graft behind the anterior flange proves that the graft becomes load bearing through stress transfer (FIG 5).

 

Stemmed implants

 

The addition of intramedullary stems to the humeral and ulnar components reduced the rates of component loosening.

 

 

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FIG 4 • A. The Latitude total elbow prosthesis. This is a hybrid implant that can be linked. Note that the implant allows for replacement of the radial head. B. The Nexel total elbow prosthesis is linked. There is no radial head component in this implant. (A: From Cooney WP, Morrey BF. Elbow arthroplasty: historical perspective and emerging concepts. In: Morrey BF, Sanchez-Sotelo J, eds. The Elbow and Its Disorders.

Philadelphia: Saunders Elsevier, 2009:705-719; B: Reprinted with permission from Matthew L. Ramsey, MD.)

 

 

Cemented stems

 

 

Cement fixation of the implants is the current standard of care.

 

Cement technique is improved with brushing and lavage of the canals, use of PMMA in a more liquid state, and cement restrictors in the humerus and ulna to occlude the canal.12

EVOLVING ISSUES IN TOTAL ELBOW ARTHROPLASTY

 

Challenges remain with TEA that continue to fuel efforts to improve the outcome of surgery.

 

There have been numerous improvements in surgical techniques and implant design. These lessons can be broadly classified as implant fixation, instability, polyethylene wear and osteolysis (the articulation), and triceps dysfunction.

 

Implant fixation

 

 

The vast majority of implants are fixed to bone with PMMA.

 

Modern cement techniques have improved.12

 

Aseptic loosening has highlighted the need to continually explore alternative techniques of implant fixation.

 

Instability

 

Instability is primarily a problem of unlinked arthroplasty.4,7,11,21,23,34

 

 

 

FIG 5 • Incorporation and maturation of the bone graft behind the anterior flange of the humeral component supports the notion that the graft hypertrophies as a result of stress transfer. (Reprinted with permission from Matthew L. Ramsey, MD.)

 

 

Constraint is a more poorly defined quality of implant geometry. It depends on the geometry of the implant

and its interaction with stabilizing soft tissues about the elbow.17

 

Greater articular constraint results in higher loading of the bone-cement interface and increased aseptic loosening. The optimal articular shape has not been determined to date, and it will need to consider a balance between the risk of instability and articular wear and loosening.

 

Polyethylene wear and osteolysis

 

 

Wear of the bearing surfaces is an expected process in any metal on polyethylene articulation.

 

Wear, osteolysis, and aseptic loosening continue to be a common cause of failure of elbow arthroplasty in certain patient populations.13,33

 

Polyethylene bushing wear, as an isolated process, is associated with posttraumatic conditions and severe

preoperative deformity.22

 

Concerns about polyethylene wear resulting in bushing failure have led to newer designs focused on increasing the thickness of the polyethylene and altering the bearing surface design.18

 

 

The benefit of modified polyethylene, such as highly cross-linked or vitamin E-impregnated polyethylene, has not been established clinically. Laboratory testing has demonstrated significantly improved wear rates compared to traditional polyethylene (Kincaid).

 

 

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The relationship of polyethylene wear to the development of osteolysis is not well established.

 

 

Osteolysis is rarely seen in the absence of a loose implant.

 

Osteolysis has been reported most commonly with the use of PMMA-precoated ulnar components16 (FIG 6).

 

Osteolysis is associated with cement, bone, polyethylene, and titanium wear particles.13 The osteolysis appears to be a multimodal event more related to particulate debris from loosening rather than the wear of the polyethylene alone.8

 

 

Triceps dysfunction

 

Triceps insufficiency is a recognized complication of TEA.5

 

The triceps mechanism is typically released from the ulna to aid in surgical exposure.

 

 

Meticulous repair of the triceps minimizes the risk of detachment.

 

Poor tissue quality, particularly in the rheumatoid patient, can be managed with an anconeus rotational flap.5

 

Leaving the triceps attached to the olecranon reduces the risk of triceps insufficiency but limits visualization, making the surgical procedure more difficult.30,31

 

Implant linkage

 

 

Hybrid implants have been introduced that allow an implant system to be inserted in an unlinked or linked fashion.

 

 

The theoretical advantage of this type of implant system is that the implant can be tailored to the specific pathology of the patient.

 

The effect of the introduction of hybrid implant and polyethylene wear on the survivorship of TEA is not known at this point.

 

 

 

FIG 6 • Osteolysis demonstrated with a PMMA-precoated ulnar component. (Reprinted with permission from Matthew L. Ramsey, MD.)

 

FUTURE EFFORTS

 

Elbow arthroplasty has a long successful track record in low-demand patients with rheumatoid arthritis and elderly patients with comminuted articular fractures of the distal humerus.

 

Durability of the implant over time and complications continue to present challenges, particularly in higher demand patients.

 

Future advances in elbow arthroplasty will likely include more durable implant fixation, more accurate positioning of the components, reduced bearing wear, and preservation of triceps strength and fewer infections.

 

 

Implant fixation

 

There have been some implants that have been inserted in cementless fashion.10,19,20,27,32

 

Successful cementless fixation will depend on the development of more anatomic stems and determining the ideal surface finish and extent of the ingrowth portion of the stems.

 

The major challenge in cementless implants remains the geometry of the intramedullary canals and achieving precise canal preparation.

 

Implant stability

 

 

The trend to perform elbow arthroplasty in higher demand patients has prompted a renewed interest in the use of unlinked devices.

 

Strategies to improve the stability of unlinked arthroplasty will include more secure initial ligament repair and accurate replication of flexion-extension axis.14,18

 

Alternative surgical approaches that retain one or both of the collateral ligaments may also allow for improved joint stability.

 

Precision implantation

 

 

Inaccurate replication of the flexion axis of the elbow as well as malpositioning of the ulnar component may lead to premature wear and loosening of linked elbow arthroplasties as well as instability of unlinked devices.1,2

 

Humeral stem loading has been shown to increase with malpositioning of a linked design, and elbow maltracking and instability occurs when the elbow is unlinked.3

 

Future developments may include the use of a computerassisted elbow arthroplasty with or without image guidance.24,25,26 These systems will not only allow for computer-guided bone resection but also computerguided prosthesis insertion and positioning.

 

Revision systems

 

 

Many total elbow systems lack revision components or instrumentation. Although long-stem cemented devices are commercially available, modular uncemented components are needed to allow for easier revision surgery and improved outcomes, especially in the setting of bone deficiency.

 

Infection

 

 

The incidence of infection of elbow arthroplasty continues to be high relative to that of other joint

replacements.6,35,36

 

Future developments will likely include minimally invasive surgical approaches to reduce tissue trauma and allow for more rapid surgery.

 

Implants with surface coatings to reduce infection will be introduced.

 

 

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Sterile tourniquets may be helpful by avoiding contamination of the surgical site. Furthermore, minimizing inflation times or avoiding the use of tourniquets completely could also prove to be beneficial.

 

SUMMARY

The reported clinical experience demonstrates that TEA successfully improves pain, motion, and function in most patients.

 

Implant durability varies depending on the underlying diagnosis and demands of the patient.

TEA is associated with a higher rate of complications compared to other arthroplasties. Areas where improvement is required have been identified.

 

 

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