Total Elbow Arthroplasty for Rheumatoid Arthritis
DEFINITION
Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory condition of unknown etiology affecting 1% to 2% of the population.
It affects females two to three times as frequently as males, and the incidence increases with age, typically peaking between 35 and 50 years of age.
Peripheral joints are often affected in a symmetric pattern.
The elbow is affected in about 20% to 70% of patients with RA, with a wide spectrum of severity.
Ninety percent of these patients also have hand and wrist involvement and 80% also have shoulder involvement.
Juvenile rheumatoid arthritis (JRA) is diagnosed based on the presence of arthritis, synovitis, or both in at least one joint lasting for more than 6 weeks in an individual younger than 16 years old.
Compared with adult-onset RA, JRA is complicated by severe osseous destruction, deformity, and soft tissue contractures.
PATHOGENESIS
The cause of RA is unknown.
Infectious etiologies have been proposed, but no microorganism has been proven to be causative.
Genetic and twin studies have demonstrated that a genetic predisposition clearly exists, and the disease is also associated with autoimmune phenomena.
In patients with RA, numerous cell types, including B lymphocytes, CD4 T cells, mononuclear phagocytes, neutrophils, fibroblasts, and osteoclasts, have been shown to produce abnormally high levels of various cytokines, chemokines, and other inflammatory mediators.
The result is inflammatory-mediated proliferation of synovial tissue, leading to soft tissue and finally bony destruction.
NATURAL HISTORY
Overall, the disease progresses from predominantly soft tissue (synovial) inflammation to articular cartilage damage and ultimately subchondral and periarticular bone destruction.
Manifestations of RA are initiated by synovitis and synovial hyperplasia resulting in pannus formation. This correlates with a boggy, inflamed elbow that is painful and with limited range of motion.
Synovial proliferation coupled with joint capsule distention may produce a compressive neuropathy with pain, paresthesias, or weakness in the ulnar or radial nerve distributions, or both.
Degeneration may progress to ligamentous erosion or disruption, or both. Clinically, the patient experiences
progressive instability as ligamentous integrity is compromised.
It may affect the annular ligament and produce radial head instability with anterior displacement.
Eventually, the medial and lateral collateral ligament complexes may be disrupted, thus causing further instability.
Prolonged synovitis leads to erosion of the cartilage followed by subchondral cyst formation and marginal joint erosions; the result is end-stage arthritis.
End-stage disease is marked by severe damage to subchondral bone and gross joint instability. At this stage, patients typically have a painful, weak, and functionally unstable elbow.
PATIENT HISTORY AND PHYSICAL FINDINGS
Patients typically describe a history of a swollen, tender, and warm elbow with diminished and painful range of motion.
This may be accompanied by a report of progressively declining function, constitutional complaints, and often polyarticular involvement.
In early stages of the disease, the elbow may appear more boggy, with impressive soft tissue swelling and erythema about the elbow.
As the disease progresses to later stages, soft tissue swelling may become less prominent and the elbow becomes more stiff and painful.
Differences in Examination Findings between Rheumatoid Arthritis and Juvenile Rheumatoid Arthritis
Elbows affected by JRA occur in younger patients as compared with elbows affected by RA. Patients with JRA also have stiffer elbows and therefore typically do not have instability.
Often, JRA patients have more joints affected by the rheumatoid process, but they also demonstrate a greater tolerance for pain.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Anteroposterior (AP) and lateral radiographs of the elbow are obtained to assess the degree of rheumatoid involvement and for preoperative planning (FIG 1). No further studies are typically required.
Classification
Although several classification systems have been proposed, the most commonly used is the Mayo Radiographic Classification System (Table 1).8
It allows monitoring of disease progression and often correlates well with clinical examination findings and patients' functional limitations.
The grading system is based on bone quality, joint space, and bony architecture and delineates four grades of progression in order of increasing severity.
P.4078
 |
 |
FIG 1 • Preoperative AP and lateral radiographs of a 38-year-old woman with JRA demonstrating advanced changes of osteopenia, joint space narrowing, and changes in subchondral architecture.
DIFFERENTIAL DIAGNOSIS
Calcium pyrophosphate deposition disease Osteoarthritis
Polymyalgia rheumatica Psoriatic arthritis
Systemic lupus erythematosus Fibromyalgia
NONOPERATIVE MANAGEMENT
Optimal care of the patient with RA requires a team-based approach between the orthopaedic surgeon, rheumatologist, and physical therapists to coordinate the full gamut of nonsurgical and surgical treatment options.
Medical Therapy
The medical management of RA continues to evolve and is highly effective.
Medical therapy includes classes of drugs known as diseasemodifying antirheumatic drugs (DMARDs),
immunomodulators, tumor necrosis factor (TNF) inhibitors, as well as other drugs targeting systemic
inflammation. These medications may be given alone or as part of combination therapy.
DMARDs include medications such as methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine.
Immunomodulators such as azathioprine and cyclosporine target the pathologic immune system but may also increase susceptibility to infection.
Anti-TNF-alpha agents can reduce pain, morning stiffness, and swollen joints by inhibiting an inflammatory cytokine called TNF-alpha. Examples of these drugs include etanercept, infliximab, adalimumab, golimumab, and certolizuman. These medications can also increase the risk of developing severe infection.
Other medications which target inflammation include anakinra, abatacept, rituximab, tocilizumab, and tofacitinib.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids, such as prednisone, may be prescribed to reduce symptoms of RA as well.
Judicious use of intra-articular steroid injections also plays a role in symptom management.
The importance of early referral to a rheumatologist for medical management cannot be overemphasized. Aggressive management of the synovitis can limit or delay the onset and severity of joint involvement. The most reliable and effective responses to antirheumatic medications are observed with therapy initiated in the early stages of the disease.
Physical Therapy
The goal of physical therapy is to encourage range of motion, functional strength, and maintenance of activities of daily living. This is accomplished by activity modification, rest, ice, and gentle exercise.
The primary objective of nonoperative management of the rheumatoid elbow is to minimize soft tissue swelling and to optimize range of motion, as preoperative range of motion is often predictive of postoperative total arc of motion after arthroscopic synovectomy as well as total elbow arthroplasty.
SURGICAL MANAGEMENT
Surgical management of the rheumatoid elbow primarily consists of synovectomy and total elbow arthroplasty.
Surgical Management of the Elbow before Total Elbow Arthroplasty
For early disease states, excellent clinical results may be achieved with synovectomy performed using open or arthroscopic techniques.
The goal of synovectomy is to relieve pain and swelling. Although this procedure has not necessarily been shown to alter the natural history of the disease, it reliably produces symptomatic relief for 5 or more years in the
majority of cases performed on elbows in the early stages of the disease process.6
The arthroscopic approach is advantageous over the more traditional open approach in that it is less invasive, is associated with less perioperative morbidity, and also allows predictable access to the sacciform recess. When open synovectomy is performed, the radial head must be excised to access and completely débride the diseased synovial tissue that exists in this region.
Open synovectomy has traditionally been accompanied by radial head excision due to1 ubiquitous
radiocapitellar and proximal radioulnar joint articular destruction and2 the need to surgically expose the sacciform recess for the requisite complete synovectomy.
It has been shown that routine radial head excision may predispose patients with RA to increasing valgus
elbow instability due to the loss of the stabilizing effect of the radial head (particularly if the medial collateral ligament is adversely affected by the rheumatoid process).9
Because the entire synovial proliferation around the radial neck can be accessed arthroscopically, a combined arthroscopic radial head excision is performed only in patients with stable elbows and preoperative elbow symptoms worsened with forearm rotation. Otherwise, a complete arthroscopic synovectomy is performed without excising the radial head.
In addition, the minimally invasive nature of an arthroscopic approach yields the potential advantages of less pain, faster recovery with earlier range of motion, and a lower rate of infection compared with an open procedure.
P.4079
 |
Table 1 Mayo Radiographic Classification System
|
Grade |
Radiographic Appearance |
Description |
Implications |
I Synovitis in
a normal-appearing joint with mild to moderate osteopenia
Often correlates with impressive soft tissue swelling on clinical examination
II Loss of joint
space but maintenance of the subchondral architecture
Varying degrees of soft tissue swelling are present.
 |
 |
III Marked by
complete loss of joint space
IIIA Bony
architecture is maintained
IIIB Associated
bone loss
IV Severe bony
destruction
The synovitis has “burned out” and the elbow is typically more stiff.
Patients often have severe pain and
 |
 |
functional limitations; functional instability may also be present if the joint's bony architecture is destroyed.
V Presence of
bony ankylosis of the ulnohumeral joint
Most commonly seen with JRA
Adapted from Morrey BF, Adams RA. Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am 1992;74(4): 479-490; Connor PM, Morrey BF. Total elbow arthroplasty in patients who have juvenile rheumatoid arthritis. J Bone Joint Surg Am 1998;80(5):678-688.
P.4080
An arthroscopic anterior capsular release may be performed at the time of the arthroscopic synovectomy to improve elbow extension. A posterior olecranon plasty may also be performed to reestablish normal concavity of the olecranon fossa.
Posteromedial capsule release should be avoided to prevent the risk of iatrogenic ulnar nerve injury. If an elbow requires a release of the posterior capsule to regain elbow flexion (typically those with 100 degrees or less of preoperative flexion), then the surgeon should perform an open ulnar nerve decompression and subcutaneous
transposition followed by complete posterior capsule release (including the posteromedial band of the medial collateral ligament).
Total Elbow Arthroplasty
This procedure is indicated for advanced (grade III or IV) RA of the elbow in patients with significant pain and limitations in activities of daily living.
Absolute contraindications include active infection, upper extremity paralysis, and a patient's refusal or inability to abide by postoperative activity restrictions.
Relative contraindications include presence of infection at a remote site and a history of infected elbow or elbow prosthesis.
Preoperative Planning
AP and lateral radiographs of the elbow are reviewed to assess humeral bow and medullary canal diameter as well as angulation and diameter of the ulnar medullary canal.
Preoperative radiographic templates may be helpful to assess preoperative radiographic magnification.
In particular for JRA patients, the canal width may be very small, and therefore the surgeon must ensure that appropriately sized implants as well as intramedullary guidewires and reamers are available.
If an ipsilateral total shoulder arthroplasty has been performed or is anticipated, a humeral cement restrictor should be used. A 4-inch humeral implant may also be considered; however, shorter, recently introduced humeral components for total shoulder arthroplasty can typically be placed even in the presence of a 6-inch humeral stem. Overlapping cement mantles and/or a short cement gap between the humeral stems of the shoulder and elbow prostheses should be avoided to reduce the risk of subsequent periprosthetic fracture.
Preoperative limitations in forearm rotation may be due in part to ipsilateral distal radioulnar joint pathology. Thus, radiographs should also be obtained of the ipsilateral shoulder and wrist.
Implant Selection for Total Elbow Arthroplasty
Implant options have traditionally been classified as linked (semiconstrained) or unlinked.
These terms are being used with decreasing frequency, however, as some unlinked implant designs have been developed that have precisely contoured components that create a degree of constraint.
Linked, semiconstrained implants inherently have about 7 degrees of varus-valgus and 7 degrees of axial rotation, “play,” whereas unconstrained implants typically refer to unlinked, resurfacing components.
The stability of unconstrained implants depends on soft tissue and ligamentous integrity. Such tissues may be destroyed by the rheumatoid inflammatory process or surgically released with semiconstrained implants without compromising stability.
Although no prospective comparisons between linked (semiconstrained) and unlinked implants have yet been performed, studies have generally reported improved survivorship with a semiconstrained design.7
The semiconstrained design is preferred because it is equally effective in pain relief and in improving range of motion and function while preserving stability without an observed increase in aseptic loosening.7
The Techniques section describes implantation of a linked, semiconstrained implant.
Polyethylene bushing wear is a challenging issue which has been implicated as a limiting factor in long-term implant durability following total elbow arthroplasty.2,5,10 Polyethylene wear has been reported after total elbow
arthroplasty with multiple implant designs.5,10 Osteolysis and loosening from particle-induced bushing wear is an important concern when considering mid- to long-term survivability of the implants, and this is of particular importance for younger patients undergoing total elbow arthroplasty, especially for posttraumatic conditions. Newer bearing designs have recently been created to address the potential issues related to polyethylene wear, including increasing the amount of polyethylene in the bushing as well as designs with conforming polyethylene and metallic-bearing surfaces. The implant described in the Techniques section uses a novel vitamin E highly cross-linked ultra-high-molecular-weight polyethylene bearing to prevent metal-to-metal contact and is designed to have improved polyethylene wear characteristics.
Failure of the locking mechanisms used to link ulnar and humeral components in total elbow arthroplasty has been reported for several implant designs.3,10 The implant described in the Techniques section employs a novel locking mechanism designed to reduce the potential for locking mechanism failure.
Sequence and Timing of Total Elbow Arthroplasty in the Patient with Polyarticular Involvement
Because RA typically affects multiple joint articulations, the timing of elbow arthroplasty should be considered with regard to the need for arthroplasties of other joints.
In general, the most disabling articulation should be addressed first. In the case of equivocal involvement in the elbow and a lower extremity joint in which arthroplasty is planned, the surgeon must consider the postoperative effects of surgery and plan accordingly.
If total elbow arthroplasty is performed first, at least 3 to 6 months should pass before lower extremity reconstruction is performed to allow adequate healing of the elbow. If the lower extremity will be addressed first, total elbow arthroplasty should be delayed until assistive ambulatory devices, which may put strain on the elbow, are no longer required.
Patients with total elbow arthroplasty should not bear weight with crutches. A platform walker may be used, provided it does not increase strain on the elbow. This may be achieved by raising the walker's arm rest to an appropriate height such that when the forearm is placed on
P.4081
the arm rest, the elbow may not be extended beyond 90 degrees of flexion.
Assessment of the Cervical Spine
Because nearly 90% of patients with RA have cervical spine involvement, approximately 30% of whom have significant subluxation, the cervical spine must be evaluated before any surgery in which intubation is planned.
Cervical spine radiographs should be routinely obtained.
If patients have neck pain, decreased range of motion, myelopathic symptoms, or radiographic evidence of instability, a magnetic resonance imaging (MRI) study should be ordered with concomitant referral to a spine surgeon to consider addressing the cervical spine pathology before elbow surgery.
Temporary Cessation of Medications before Total Elbow Arthroplasty
TNF inhibitors affect the immune system and have been found to increase the risk of developing a prosthetic joint infection.
In general, anti-TNF agents are typically stopped for a period of time preoperatively based on the half-life of the specific drug and for about 2 weeks after surgery to reduce the risk of perioperative morbidity.
Methotrexate is generally continued in the perioperative period. Fewer complications, infections, and flares have
been reported when methotrexate is continued perioperatively versus discontinuing it.
Patients on chronic NSAIDs should stop taking those medications approximately 2 weeks before surgery to reduce the risk of increased bleeding.
For patients on chronic steroids, stress-dose steroids may be required perioperatively.
Communications with the patient's rheumatologist and the anesthesiologist are imperative to coordinate these efforts.
Positioning
Intravenous antibiotics are administered 30 to 60 minutes before the incision.
The patient is placed in a supine position on the operating table with a rolled towel under the ipsilateral scapula. The arm is placed across the chest, and another rolled towel is placed under the elbow to support the arm.
The entire operative extremity and shoulder girdle is prepared and draped; a sterile tourniquet is placed. An Ioban drape is placed circumferentially over all exposed skin.
The arm is exsanguinated and the tourniquet inflated.
Approach
Multiple exposures, including triceps-on approaches, may be used to perform total elbow arthroplasty. The Bryan-Morrey approach (triceps-anconeus “slide”) provides excellent exposure and is particularly useful for surgeons with limited experience in triceps-sparing approaches. The Bryan-Morrey approach is described in the following text.
TECHNIQUES
Incision and Exposure
A straight incision, measuring approximately 15 cm and centered at the elbow joint, is made just lateral to the tip of the olecranon.
The ulnar nerve is carefully identified and isolated along the medial aspect of the triceps.
Proximal neurolysis of the nerve is achieved by releasing the arcade of Struthers from the medial head of the triceps. The nerve is then mobilized to beyond its first motor branch distally by dividing Osborne fascia and the fascia between the two heads of the flexor carpi ulnaris (FCU) (TECH FIG 1A,B).
TECH FIG 1 • A,B. The ulnar nerve is identified along the medial border of the triceps, and a vessel loop is
 |
 |
placed. (continued)
The medial intermuscular septum is excised and a deep pocket of subcutaneous tissue over the flexor pronator group distally and anterior to the triceps proximally is created.
The nerve is then anteriorly transposed into this subcutaneous tissue pocket; it must be protected throughout the operation.
An incision is then made over the medial aspect of the ulna between the anconeus and FCU. The medial triceps and anconeus are subperiosteally elevated off the ulna.
The medial aspect of the triceps is retracted along with the fibers of the posterior capsule to tension the Sharpey fibers at their ulnar insertion (TECH FIG 1C,D).
P.4082
 |
 |
 |
TECH FIG 1 • (continued) C,D. Under tension, the medial and ulnar border of the triceps (C) and the anconeus (D) are incised from their insertions into the olecranon. E. The fibers of the extensor mechanism are further reflected laterally. F. The extensor mechanism is slid lateral to the lateral condyle. G. The medial collateral ligament is released to give the elbow maximal motion and to facilitate complete exposure
of the ulnohumeral joint.
P.4083
These fibers are then sharply dissected, and the triceps in continuity with the anconeus is reflected from medial to lateral (TECH FIG 1E).
The lateral ulnar collateral ligament complex is released from its humeral attachment, thus allowing the extensor mechanism to be completely reflected to the lateral aspect of the humerus (TECH FIG 1F).
If ulnohumeral ankylosis is present, as is sometimes the case in JRA patients, a saw or osteotome may be necessary to reestablish the joint line and to create the osteotomy at the appropriate center of rotation of the ulnohumeral joint.
The elbow is then progressively flexed, exposing the medial collateral ligament, which is then released subperiosteally from its humeral attachment (TECH FIG 1G).
The tip of the olecranon is removed with a rongeur or oscillating saw, depending on the quality of the bone, and the humerus is then externally rotated and the elbow fully flexed to adequately expose the articulating surfaces of the humerus, ulna, and radial head.
The anterior capsule is completely released from the anterior aspect of the humerus to accommodate the flange of the humeral component and to allow unencumbered postoperative elbow extension.
-
Humeral Preparation
Trochlear resection: The midportion of the trochlea is removed with an oscillating saw if the bone is dense or with a rongeur if the bone is soft, up to the roof of the olecranon fossa.
The resected bone should be preserved for the anterior distal humeral bone graft needed later in the procedure (TECH FIG 2A).
Humeral canal reaming: The proximal base of the olecranon fossa is entered with a rongeur or burr, and the humeral awl reamer is then used to identify the humeral medullary canal (TECH FIG 2B,C). This reamer must be centered and must fit between the remaining portions of the trochlea to ensure that the humeral rasps can be seated in the canal. Additional bone should be resected if needed to accommodate the humeral rasp width.
 |
 |
 |
 |
TECH FIG 2 • A. Following trochlear resection with an oscillating saw. B. A burr is used to enter the roof of the olecranon. C. The humeral awl reamer is used to identify the medullary canal. D. Progressive humeral canal rasping is performed up to the desired size and fit. E. The humeral canal rasp is seated so that the solid line matches the axis of flexion. (continued)
Humeral canal rasping: The pilot humeral rasp is used initially (TECH FIG 2D) and it is impacted until the solid line on the rasp reaches the axis of flexion (TECH FIG 2E). Progressively larger rasps are used to achieve the desired size and fit for the planned implant, and the final rasp is left in place. A humeral alignment rod can be placed through the rasp to help determine the axial alignment (TECH FIG 2F).
P.4084
 |
 |
 |
 |
TECH FIG 2 • (continued) F. The humeral cut guide is placed and secured, and an oscillating saw is used to make vertical cuts. G. The trephine stabilizer is fully seated in the canal, and the trephine saw is advanced until it reaches the depth stop. H. The humeral provisional is fully seated. I. A rongeur is used to remove excess bone from the condyle distal to the provisional. J. After resection, the humeral provisional is flush with the distal aspect of the humeral condyles.
Superficial trephine cut: A size-matched trephine saw based on the final humeral rasp is then used to define the planned humeral cut. A pilot pin is placed into the humeral rasp, and the trephine saw is advanced over this until the depth stop is reached. The posterior aspect of the humerus is scored with the trephine to provide a reference for the final preparation.
Humeral cut: The humeral cut guide is attached to the humeral rasp, and an oscillating saw is used to excise remaining trochlea with vertical cuts to accommodate placement of the trephine stabilizer (TECH FIG 2F).
Care must be taken, as this area may be very thin in patients with RA and thus susceptible to fracture.
The trephine stabilizer is placed into the canal. Full seating may require notching of the coronoid fossa with a burr or rongeur.
The trephine's pilot pin is placed into the trephine stabilizer and advanced to its depth stop (TECH FIG 2G). The trephine cut is then completed.
The size-matched humeral provisional is seated in the canal, and excess bone is removed to make the provisional flush with the distal aspect of the condyles (TECH FIG 2H).
-
Ulnar Preparation
P.4085
Ulnar canal exposure: The tip of the olecranon is removed with an oscillating saw. Exercise caution with this step because overresection weakens the triceps insertion site, whereas underresection causes the intramedullary rasp to be malaligned relative to the axis of the ulna. This may then result in malalignment of the ulnar component and possible dorsal cortex perforation.
A high-speed burr is angled 45 degrees relative to the axis of the ulnar shaft at the junction of the sigmoid fossa and coronoid to identify the ulnar medullary canal (TECH FIG 3A,B).
The olecranon is notched with a rongeur to allow the reamers and rasps to be placed in line with the ulnar canal.
Ulnar canal reaming (if necessary): The ulnar awl reamer is centered in the ulna and advanced to open the ulnar canal.
The ulnar bow should be acknowledged and palpated while inserting the ulnar reamers to avoid ulnar perforation.
The ulnar canal is progressively reamed with solid flexible reamers until the desired size is reached (TECH FIG 3C). Flexible cannulated reamers with a ball-tip guidewire are used to continue reaming as necessary. The ball tip is used to avoid cortical penetration.
![]()
![]()
![]()
TECH FIG 3 • A,B. The olecranon tip is resected, and a high-speed burr is used to open the ulnar medullary canal at the base of the coronoid. C. The flexible, solid, and cannulated ulnar awl reamers are progressively advanced prior to rasping. The surgeon's hand is placed over the ulnar shaft to guide aiming of the reamers and rasps down the center of the canal. D,E. The pilot ulnar rasp is advanced until the center of the rasp matches the center of the sigmoid notch. (continued)
Ulnar canal rasping: The ulnar canal is further prepared with the pilot ulnar rasp. The rasp is fully seated, and the canal is progressively rasped until the desired fit is achieved.
During advancement of the rasps, it is important to maintain proper rotation of the rasp so that the handle is perpendicular to the flat dorsal aspect of the proximal ulna (TECH FIG 3D,E). The final rasp and T handle are left in the canal.
Sigmoid notch preparation: The ulnar clearance template is placed through the ulnar rasp to ensure adequate clearance around the sigmoid notch to allow articulation (TECH FIG 3F). Any osseous impingements encountered when rotating the template are then removed with a burr or rongeur. The template is then moved to the other side of the ulnar rasp, and the process is repeated.
The tip of the coronoid is removed with a rongeur to eliminate impingement and improve flexion (TECH FIG 3G).
Ulnar provisional: The ulnar provisional is placed into the ulnar canal and lightly impacted if necessary to align the center of the
P.4086
ulnar provisional with the center of the greater sigmoid notch. A humeral-bearing pin may be used to assess rotational and varus/valgus alignment.
![]()
![]()
TECH FIG 3 • (continued) F. The ulnar clearance template is rotated around the sigmoid notch. Any excess bone noted when scoring the surface of the bone is then excised. G. The tip of the coronoid is removed to eliminate impingement and improve flexion.
Because proximal radioulnar arthritis is ubiquitous in patients with RA and JRA and the Nexel total elbow arthroplasty does not require proximal radioulnar and radiocapitellar reconstruction, a radial head excision is performed.
This may be performed by rotating the forearm and using a rongeur to progressively excise the radial head from an axial orientation while holding the elbow in full flexion.
-
Trial Reduction
The humeral provisional is then reinserted, the components are coupled, and a trial reduction is performed (TECH FIG 4A).
Range of motion is tested and should be full without limitation in the flexion-extension plane (TECH FIG 4B).
If range of motion is limited owing to inadequate soft tissue release, this should be addressed at this time.
The components should also be evaluated for bony impingement, which may occur posteriorly (olecranon impingement on the humerus) or anteriorly (coronoid tip on the anterior flange of the humeral component). Any impinging bone should be removed with a rongeur.
![]()
![]()
![]()
![]()
TECH FIG 4 • A,B. A trial reduction of the components is performed and range of motion is assessed to evaluate for bony impingement.
Incomplete seating of the humeral and/or ulnar components may also be a cause for limitations in elbow extension.
If humeral bowing is present, it may be difficult to fully seat the humeral provisional. In this case, the proximal aspect of the final humeral component may be bowed to match the humeral canal and allow complete seating of the prosthesis.
After satisfactory trial reduction, the provisional components are removed.
P.4087
Cementing
Both medullary canals are then pulse lavaged and dried.
Based on the trial components used, the length of the cement applicator is measured to equal that of the humeral component.
The tip of the applicator is cut at this level to ensure appropriate depth of the cement down the humeral canal (TECH FIG 5A).
A humeral cement restrictor is placed to the desired depth.
It is recommended that cementing of the components be performed separately.
Cement with antibiotics are mixed and injected with a relatively soft consistency.
![]()
![]()
TECH FIG 5 • A,B. Separate cementing of the humeral and ulnar medullary canals is recommended. C. The ulnar stem inserter is used to prevent scratching of the ulnar component while fully seating the implant.
The humeral component is typically cemented first, followed by the ulnar component (TECH FIG 5B).
The ulnar stem inserter is used to protect the ulnar component from being damaged during insertion (TECH FIG 5C). The implant must be in line with the flat dorsal surface of the olecranon and it must be fully seated so that the center of the component is in the center of the greater sigmoid notch.
Care is taken to remove excess cement from around the ulnar component to prevent third-body wear. A plastic curette is used to avoid implant scratching.
-
Humeral Component and Bone Graft
P.4088
A small (about 2 × 2 cm and 2 to 4 mm thick) piece of the removed trochlea is used for the anterior bone graft. Radial head or allograft may be used in revision cases when no bone is resected from the trochlea.
This bone graft is wedged between the anterior aspect of the humerus and the flange as the humeral component is placed (TECH FIG 6).
This provides the humeral component with rotational stability as well as additional stability in the AP plane. Excess cement is removed from the area around the humeral component with a plastic curette.
![]()
![]()
![]()
TECH FIG 6 • The humeral component is inserted to the optimal depth that allows proper articulation with the ulnar component.
-
Assembly and Impaction
Assembly of ulnar bearing: The axle pin is placed through the eye of the ulnar component, and the ulnar-bearing assembly tool is used to attach the ulnar bearings (TECH FIG 7A).
The axle pin and the tabs of the ulnar bearings are aligned with the humeral component slots to reduce the joint. Pressure is applied to the forearm to drive the axle pin and bearings into the humeral component.
Reduction of the joint is completed by applying and squeezing the articulation inserter. The top “feet” of the inserter fits into the ulnar-bearing tab pockets and the bottom of the inserter fits into the proximal posterior hole of the humeral component. Squeezing the inserter should make the ulnar bearings flush with the
curved distal surfaces of the humeral component (TECH FIG 7B).
![]()
![]()
TECH FIG 7 • A. The ulnar-bearing assembly tool is squeezed until significant resistance is felt to attach the ulnar bearing. There is no audible click. B. The articulation inserter is applied and squeezed until resistance is felt and the bearings are seated. There is no audible click with this maneuver. (continued)
Humeral screw placement: The bearings must be flush with the humeral component in order to insert the humeral screws. The ulnar-bearing tamp may be used to press the bearings in place if needed.
Insert the humeral screws in the medial and lateral screw holes of the humeral component by using the humeral screw holder. Screws are sequentially tightened to the prescribed torque, and each screw should be alternately tightened until it is snug before performing the final torque on either screw.
The final torque is achieved when an audible “click” is heard from the torque screwdriver (TECH FIG 7C).
Range of motion is checked and a full arc of motion is confirmed. Any soft tissue contractures or bony impingements are addressed at this time.
P.4089
![]()
![]()
![]()
![]()
TECH FIG 7 • (continued) C. Linked components after the humeral screws are tightened.
-
Triceps Reattachment
Small cruciate and transverse drill holes are placed through the olecranon at the site of triceps reattachment, and a heavy, nonabsorbable suture (such as no. 5 Ethibond) is placed on a Keith needle and then brought through the distal medial cruciate drill hole and out the proximal lateral hole (TECH FIG 8A-C).
The elbow is flexed to about 60 degrees and the extensor mechanism is reduced over the tip of the olecranon; consider slightly overreducing the extensor mechanism medially to minimize the potential for postoperative lateral subluxation.
The suture is woven through the triceps tendon in a locking, crisscross pattern such that the suture emerges at the proximal medial hole (TECH FIG 8D).
The suture is then passed through this hole and out the distal lateral hole such that it is located directly across from the initial suture end.
![]()
![]()
TECH FIG 8 • Cruciate (A,B) and transverse (C) drill holes are placed in the ulna for triceps reattachment on a Coonrad-Morrey total elbow replacement. The repair for the Nexel total elbow arthroplasty is identical to this repair when the Bryan-Morrey approach is performed. (continued)
These suture ends are then passed again through the forearm extensor fascia and tied together.
Two reinforcing sutures are then passed through the transverse holes and extensor fascia before being tied together.
Avoid knots directly over the subcutaneous border of the proximal ulna.
The tourniquet is then deflated, and hemostasis is achieved with bipolar electrocautery. The medial soft tissue extensor mechanism is then reapproximated.
P.4090
![]()
![]()
![]()
TECH FIG 8 • (continued) D. Planned triceps repair. E. Suture is passed through the proximal ulna and then woven through the triceps tendon before being tied together.
-
Ulnar Nerve Transposition and Wound Closure
The protected nerve is in the subcutaneous tissue pocket previously created, and dermal sutures are placed to protect and secure the nerve (TECH FIG 9).
Wounds are closed in layers, and a drain is placed. Staples are used to close the skin.
An anterior splint is placed with the elbow in full extension, making sure to adequately pad the anterior aspect of the splint both proximally and distally to prevent skin breakdown.
![]()
![]()
![]()
![]()
TECH FIG 9 • The ulnar nerve is transposed into the subcutaneous tissue of the medial epicondylar region and secured with sutures in the dermal layer.
P.4091
PEARLS AND PITFALLS
Approach ▪ Take your time with the Bryan-Morrey approach; maintaining precise and exposure subperiosteal elevation of the extensor mechanism will make for a better
postoperative extensor mechanism repair.
Humeral ▪ Shorten the humerus by up to 1 cm to augment postoperative range of motion without compromising strength if needed.
-
Obtain complete ulnohumeral dissociation before bony preparation. This includes complete releases of the lateral ulnar collateral ligament and medial collateral ligament complexes and a complete anterior capsule release.
-
Consider reflection of common flexors or extensors if severe deformities or arthrofibrosis is present.
preparation
-
Use a burr distally to open up the humeral canal if needed rather than forcing with rasps.
Radial and ulnar preparation
-
Excise the radial head and the tip of the coronoid.
-
Always palpate the ulna and consider the ulnar bow before ulnar preparation to avoid perforation.
-
Cementing ▪ Review the cement technique and order mentally before proceeding; use cement that does not rapidly set.
Triceps reattachment
-
Overreduce the triceps-anconeus repair medially.
Postoperative care
-
Use a postoperative extension splint for 24-36 hours.
-
Make all efforts to reduce postoperative swelling.
POSTOPERATIVE CARE
Postoperatively, the anteriorly placed splint maintains the elbow in full extension for about 24 to 36 hours. The elbow is strictly elevated overnight and on postoperative day 1.
The drain is removed on postoperative day 1 or when output is less than 30 mL in an 8-hour period.
After splint removal, open-chain active-assisted range of motion is allowed. A formal physical therapy consultation is not usually required.
The patient is restricted to no pushing and no overhead activities for 3 months to protect the triceps. In addition, no repetitive lifting of objects heavier than 5 pounds and no lifting greater than 10 pounds in a single event is recommented to maximize the survivorship of the implant.
 |
FIG 2 • A,B. A 66-year-old female with long-standing RA and Mayo grade IV changes. (continued)
OUTCOMES
Successful outcomes for total elbow arthroplasty are judged based on relief of pain and improved range of motion, stability, and function.
The Mayo Elbow Performance Score assigns numeric values to each of these categories to produce
scores for each of these criteria as well as an overall score.8 Outcomes are often compared using this system.
Total elbow arthroplasty for RA (FIG 2)
In the largest study with the longest follow-up in the literature, Gill and Morrey4 reported 86% good or excellent results with a 13% reoperation rate on 69 patients with RA treated with a semiconstrained total elbow arthroplasty. Forty-four of these patients were followed for more than 10 years.
P.4092
 |
 |
FIG 2 • (continued) C,D. Postoperative radiographs following Nexel total elbow arthroplasty.
The prosthetic survival rate was 92.4% at 10 years of follow-up, thus approaching the success of lower extremity arthroplasty.
Total elbow arthroplasty for JRA
Connor and Morrey1 reported 87% good or excellent results on 19 patients (24 elbows) followed for a mean of 7.4 years.
The mean improvement in the Mayo Elbow Performance Score was 59 points, 96% had little or no pain, and there was no evidence of loosening in any prostheses at the latest follow-up.
The mean flexion-extension arc of motion improved by only 27 degrees (from 67 to 90 degrees) in this study, which is reflective of the severe soft-tissue contractures associated with JRA.
COMPLICATIONS
Infection
Aseptic loosening Mechanical failure
Short term Long term
Ulnar nerve injury
Triceps weakness or avulsion Ulnar component fracture Ulnar fracture
Wound healing problems
REFERENCES
-
Connor PM, Morrey BF. Total elbow arthroplasty in patients who have juvenile rheumatoid arthritis. J Bone Joint Surg Am 1998;80(5): 678-688.
-
Day JS, Baxter RM, Ramsey ML, et al. Characterization of wear debris in total elbow arthroplasty. J Shoulder Elbow Surg 2013;22: 924-931.
-
Figgie MP, Su EP, Kahn B, et al. Locking mechanism failure in semiconstrained total elbow arthroplasty. J Shoulder Elbow Surg 2006;15: 88-93.
-
Gill DR, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten- to fifteen-year followup study. J Bone Joint Surg Am 1998;80(9):1327-1335.
-
Horiuchi K, Momohara S, Tomatsu T, et al. Arthroscopic synovectomy of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 2002;84-A(3):342-347.
-
Kelly EW, Coghlan J, Bell S. Five- to thirteen-year follow-up of the GSB III total elbow arthroplasty. J Shoulder Elbow Surg 2004;13: 434-440.
-
Little CP, Graham AJ, Karatzas G, et al. Outcomes of total elbow arthroplasty for rheumatoid arthritis: comparative study of three implants. J Bone Joint Surg Am 2005;87(11):2439-2448.
-
Morrey BF, Adams RA. Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am 1992;74(4):479-490.
-
Rymaszewski LA, Mackay I, Amis AA, et al. Long-term effects of excision of the radial head in rheumatoid arthritis. J Bone Joint Surg Br 1979;66(1):109-113.
-
Wright TW, Hastings H. Total elbow arthroplasty failure due to overuse, C-ring failure, and/or bushing wear. J Shoulder Elbow Surg 2005;14:65-