1. ELBOW ARTHROPLASTY IN TRAUMATOLOGY Frédéric Schuind, Wissam El Kazzi Université libre de Bruxelles, Brussels, Belgium

2. 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)

3. Elbow arthroplasty in traumatology Goals after a fracture : –To regain, as quickly as possible, full painless motion, joint stability and strength –Pain ?

5. Elbow arthroplasty in traumatology Goals after a fracture : –To regain, as quickly as possible, full painless motion and joint stability –Pain ? –Full motion ?

6. 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

7. 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

8. Elbow arthroplasty in traumatology Resurfacing implants of total elbow arthroplasty : Sorbie-Questor unlinked TEA

9. 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

10. 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°)

11. Elbow arthroplasty in traumatology Semi-constrained Coonrad-Morrey total elbow arthroplasty :

12. Elbow arthroplasty in traumatology Semi-constrained Coonrad-Morrey total elbow arthroplasty : Motion under muscle stabilization

13. 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

14. 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

15. Elbow arthroplasty in traumatology Latitude total elbow arthroplasty : –Allowing hemiarthroplasty if indicated From Levine WN (Internet)

16. 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)

17. 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)

18. 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

19. Elbow arthroplasty in traumatology Distal humerus fractures : –1 to 2% of adult fractures –Severe lesions : Most fractures are intraarticular and displaced AO classification

20. Elbow arthroplasty in traumatology AO classification of distal humerus fractures

21. 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)

22. 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) ?

23. Elbow arthroplasty in traumatology Comminuted fractures of the distal humerus in the elderly patient :

24. 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

25. 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 ?

26. 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

27. 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

28. 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 ( no definitive conclusion concerning the long-term results after TEA Experience and judgment of the surgeon !

29. 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 :

30. 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

31. 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)

32. 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

33. Elbow arthroplasty in traumatology Clinical example : –68 y.o. left-handed woman –C3 comminuted, closed fracture of left distal humerus after a simple fall

34. Elbow arthroplasty in traumatology Clinical example :

35. Elbow arthroplasty in traumatology Clinical example, 14 th postoperative months X-rays :

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

37. Elbow arthroplasty in traumatology Second example : –60 y.o. female interpreter –Closed comminuted fracture of left trochlea and capitulum (C3) –Coonrad Morrey TEA

38. 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 !

39. 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

40. Third clinical example : –External fixation > insufficient reduction, persistence of radial head dislocation –Internal fixation, insufficient stability, re-dislocation –New external fixation, re-dislocation

41. Elbow arthroplasty in traumatology Third clinical example : –Coonrad-Morrey TEA

42. Elbow arthroplasty in traumatology Third clinical example, 16 th 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

43. 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)

44. 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 ?

45. Elbow arthroplasty in traumatology

46. Conclusions (2) : –Present indications given the recent development of locked plates ? –Indications of unlinked arthroplasty (Kalogrianitis et al, 2008) ? of hemiarthroplasty ?

47. Frédéric Schuind Université libre de Bruxelles, Brussels, Belgium 18 million light-years – Credit : Boomsma R., Oosterloo T., Fraternali F., Sancisi R., van der Hulst M.J. - NASA