Elbow Arthroplasty Masterclass: Reconstructing Posttraumatic Elbows

Introduction to Posttraumatic Elbow Reconstruction: An Intraoperative Masterclass

Alright, fellows, gather around. Welcome to the operating theater. Today, we're tackling one of the most challenging areas in orthopaedics: the posttraumatic elbow. This isn't just about fixing a fracture; it's about restoring a complex, highly functional joint after it's been ravaged by injury, failed treatments, or chronic instability. These cases demand meticulous planning, precise execution, and a deep understanding of elbow biomechanics and anatomy.

Understanding the Pathology: What Are We Facing?

When we talk about posttraumatic conditions of the elbow, we're referring to a spectrum of disorders that arise as a direct consequence of previous injury. It's crucial to understand these underlying pathologies as they dictate our surgical strategy.

• Posttraumatic Arthritis: This is a primary pathology involving the degeneration of the articular surface itself. Think of it as accelerated wear and tear in an already compromised joint.
  • Secondary Pathologies: Often, this arthritis doesn't come alone. We frequently encounter associated issues like severe contracture, loose bodies within the joint space, and heterotopic ossification, all contributing to pain and functional limitation.
• Nonunion of the Distal Humerus: When a distal humeral fracture fails to heal, it can lead to significant instability and pain.
  • Management Considerations: In situations where reconstruction of this nonunion is deemed either impossible due to extensive bone loss or undesirable due to patient factors, a total elbow arthroplasty (TEA) becomes a viable, and often necessary, salvage option.
• Dysfunctional Instability of the Elbow: This is a particularly challenging clinical situation where the very fulcrum of stable elbow function has been compromised or lost entirely. Imagine the forearm losing its stable connection to the brachium.
  • Clinical Presentation: You might see radiographs demonstrating a clear dissociation of the forearm from the brachium, as illustrated in our patient's pre-op films here. This often stems from inadequately treated distal humerus fractures with resultant nonunion, leading to a flail elbow.
    

    
    
    

FIG 1 • Radiograph demonstrating dissociation of the forearm from the brachium in a patient with an inadequately treated fracture of the distal humerus with resultant nonunion.
* Chronic Ligamentous Instability (Dislocation): Persistent instability or recurrent dislocation of the elbow, especially in elderly or osteopenic patients, can inevitably lead to progressive articular degeneration. The joint surfaces are constantly grinding and impacting abnormally.

Ultimately, the treatment for these posttraumatic conditions is highly individualized. We must consider the specific underlying pathology, the patient's functional demands, their activity level, and, of course, their age. A young, active patient will have very different needs and expectations compared to an older, more sedentary individual.

Comprehensive Patient Evaluation and Preoperative Planning

Before we even consider making an incision, a thorough understanding of the patient's history, physical findings, and imaging is paramount. This is where we formulate our surgical strategy.

Patient History and Physical Findings

Our patient history is meticulously directed at gathering every piece of relevant information:
* Initial Injury: What was the mechanism? What structures were initially damaged?
* Previous Treatments: What interventions have been undertaken? Was it conservative, or were there previous surgeries? What were the outcomes?
* Complications of Treatment: Were there any infections, nerve injuries, or hardware failures from prior interventions?
* Presenting Complaints: What are the patient's primary concerns today? Pain, instability, stiffness, mechanical symptoms?
* Patient Expectations: Crucially, what does the patient hope to achieve with surgery? Are their expectations realistic given the complexity of their condition?

A detailed investigation of the patient’s symptoms should include specific questions regarding:
* The degree of pain and its impact on daily activities.
* The presence of instability – does the elbow feel like it gives way?
* The presence of stiffness – what activities are limited by reduced motion?
* Any mechanical symptoms such as catching, clicking, or locking, which might indicate loose bodies or articular surface irregularities.

The physical examination of the elbow must follow a systematic, reproducible approach.

1. Inspection of the Elbow:
   • We immediately look for the presence and location of previous skin incisions or any persistent wounds, which will influence our surgical approach.
   • We assess the overall alignment of the extremity at rest, looking for any gross deformities.
   • We check for prominent hardware from previous surgeries, as this may need to be addressed.
     

     
     
     

Imaging and Other Diagnostic Studies

Imaging is our window into the joint's internal architecture.

• Radiographs: Orthogonal radiographic views (AP and lateral) of the elbow are mandatory.
  • Oblique Radiographs: These can be very helpful in obtaining more detailed views of specific areas, especially for subtle fractures or osteophytes.
  • Lateral Radiograph: Typically, a good lateral radiograph is relatively easy to obtain.
  • Anteroposterior (AP) Radiograph: A useful AP radiograph can be challenging, particularly if the patient presents with a significant flexion contracture. A poorly positioned AP radiograph can make accurate assessment of the joint space difficult, often leading to an overestimation of the amount of joint destruction.
• CT Scans: These are particularly helpful in assessing the integrity of the bone and establishing whether the joint space is reasonably preserved. They are invaluable for evaluating complex fractures, nonunions, and the presence of heterotopic ossification or loose bodies.
  • Three-Dimensional Reconstructions: These provide an even better understanding of any complex deformity, aiding in preoperative templating and surgical planning.
• Magnetic Resonance Imaging (MRI): While excellent for soft tissue assessment, MRI is rarely needed in the initial assessment of a posttraumatic joint unless there's a specific concern for occult ligamentous injury not visible on other modalities, or a soft tissue mass. Therefore, it is used sparingly in this context.

Differential Diagnosis

When evaluating a posttraumatic elbow, we consider:
* Nonunion or malunion of the distal humerus.
* Posttraumatic stiffness of the elbow.
* Chronic dislocation of the elbow.
* Revision surgery for failed previous interventions.

Nonoperative Management

The success of nonoperative management hinges on the specific features of the pathology, the patient's motivation, and their functional goals.
* Activity Modification: This is often the first line, aimed at reducing the forces across the elbow that aggravate symptoms.
* Range of Motion Maintenance: We encourage maintaining existing range of motion. However, aggressive efforts to regain lost motion can actually aggravate the inflamed or arthritic joint.
* External Bracing: Occasionally used to provide support to an unstable extremity. However, in general, bracing is often poorly tolerated by patients and can be functionally limiting.

Surgical Options and Preoperative Planning

When nonoperative management fails or is deemed inappropriate, we turn to surgical intervention. Our choice of surgical option is always directed at addressing the underlying cause of disability, carefully considering the patient’s age, physical requirements, and expectations.

Interposition Arthroplasty

This procedure is designed to resurface the joint with biological tissue, providing a smooth gliding surface and improving motion.

• Indications:
  • Patients experiencing pain or significant loss of range of motion who have failed to respond to appropriate nonoperative management.
  • Posttraumatic arthritis in patients who are either too young for a total elbow arthroplasty (TEA) or who are unwilling to accept the functional restrictions associated with TEA.
  • The best candidates for interposition arthroplasty are those with painful loss of motion where there is no requirement for aggressive, heavy use of the extremity. This is a crucial patient selection point.
• Contraindications:
  • Active infection or septic arthritis with persistent infection.
  • Grossly unstable elbow, where the interposition alone would not provide adequate stability.
  • Marked angular deformity that cannot be corrected with soft tissue release and reshaping.
  • Pain without associated functional loss – surgery is not for pain alone if function is preserved.
  • Inadequate bone stock to support the graft.
  • Patients unable or unwilling to follow strict postoperative instructions.
• Graft Options:
  • Achilles Tendon Allograft: This is a popular choice due to no donor site morbidity and its robust nature. A significant advantage is its versatility; it can also be used to reconstruct collateral ligaments if necessary, which is often the case in posttraumatic settings.
  • Dermis or Fascia Lata Autogenous Graft: These are options, but they come with donor site morbidity.
  • Dermal Tissue Allograft: Another allograft option.
• Salvage: It is imperative that the surgeon undertaking an interposition arthroplasty is comfortable performing a total elbow replacement in the face of failure, as a failed interposition arthroplasty often necessitates a TEA as the salvage procedure.

Total Elbow Replacement (TEA)

TEA is considered for more severe conditions, particularly when reconstruction is impossible or undesirable.

• Patient Profile: Patients undergoing TEA for posttraumatic conditions tend to be younger than those undergoing TEA for other indications (e.g., rheumatoid arthritis).
• Indications for TEA in Posttraumatic Cases:
  • Patients who have failed to respond to appropriate nonoperative management.
  • Patients who are not appropriate candidates for other surgical options, such as interposition arthroplasty or open reduction and internal fixation.
  • Patients who are willing to adopt a more sedentary lifestyle, as TEA carries activity restrictions.
  • Patients with no absolute contraindications to the procedure (e.g., active infection, inadequate bone stock, inability to comply with postoperative instructions).
• Implant Characteristics: Implants are described by their physical linkage and constraint.
  • Linkage: Determines if the components are physically connected.
    • Linked (Semiconstrained) Designs: These implants have the advantage of being universally applicable to virtually all posttraumatic conditions of the elbow, providing inherent stability.
    • Unlinked Designs: These require integrity of the collateral ligaments and limited deformity, such that normal anatomic relationships can be re-established. They rely heavily on soft tissue stability.
    • Linkable Designs: A hybrid approach, offering the benefits of an unlinked implant while allowing conversion to a linked design if intraoperative stability cannot be achieved or if instability develops postoperatively.
  • Constraint: A more poorly defined quality, dependent on the implant's geometry and its interaction with the surrounding soft tissues.
• Implant Selection in Posttraumatic Arthritis: For posttraumatic arthritis, linked (semiconstrained) designs are often favored due to the inherent instability and soft tissue compromise often present.

Patient Positioning in the OR

Proper patient positioning is critical for optimal exposure and manipulation of the elbow joint.

• Interposition Arthroplasty Positioning:
  • Supine Position: The patient is placed supine with the ipsilateral arm across the chest, supported by a bump or bolster under the shoulder. This allows for excellent access to both medial and lateral aspects of the elbow.
  • Lateral Decubitus Position: Alternatively, the patient can be placed in a lateral decubitus position with the arm draped over an arm holder. This provides gravity assistance for elbow flexion and extension.
• Total Elbow Replacement Positioning:
  • Patients are placed supine on the operating table with a bump under the ipsilateral shoulder. This elevates the shoulder slightly, bringing the elbow into a more accessible plane.
  • Arm Mobility: Crucially, the arm should be freely mobile through the shoulder to allow full manipulation of the joint throughout surgery, which is essential for implant seating and range of motion assessment.
  • Arm Placement: The arm can then be placed across the body on a bolster or externally rotated through the shoulder and flexed at the elbow, depending on surgeon preference and the specific approach.
    

    
    
    

FIG 3 • Patient positioning for total elbow arthroplasty with the arm across the body supported on a bolster.

Intraoperative Execution: Interposition Arthroplasty

Alright, fellows, let's scrub in. We've planned this meticulously. Our patient today presents with significant posttraumatic arthritis, pain, and stiffness, but good bone stock and is too young for a TEA, making interposition arthroplasty our chosen path.

1. Skin Incision and Initial Exposure

"Scalpel, please. We'll start with a straight posterior skin incision, slightly off the medial aspect of the olecranon to protect the ulnar nerve. This allows us to develop generous medial and lateral subcutaneous flaps. Remember, a well-planned incision is the first step to a successful exposure."

• Surgical Directive: Make a 10-12 cm posterior incision, extending proximally along the posterior humerus and distally along the ulna.
• Anatomy: The skin here is relatively thin. We're going through subcutaneous fat to the deep fascia.
• Pearl: Avoid undermining too aggressively, especially in areas of previous scarring, to preserve vascularity of the skin flaps.

2. Ulnar Nerve Isolation and Transposition

"Now, let's identify and protect our ulnar nerve. This is absolutely critical. We'll trace it from proximally in the cubital tunnel, through the arcade of Struthers if present, and distally into the flexor carpi ulnaris. Given the posttraumatic nature, there may be significant scarring. Once identified, we'll transpose it anteriorly to prevent impingement after the elbow is reconstructed and to protect it throughout the procedure."

• Surgical Directive: Carefully dissect the ulnar nerve from its bed, releasing any fascial attachments or scar tissue. Use a small right angle or nerve hook for gentle isolation. Mobilize it sufficiently to allow anterior transposition without tension.
• Anatomy: The ulnar nerve passes posterior to the medial epicondyle in the cubital tunnel. It is superficial here and highly vulnerable. Proximally, it may pass beneath the arcade of Struthers. Distally, it enters the two heads of the flexor carpi ulnaris.
• Surgical Warning:
  > Surgical Warning: Meticulous, gentle dissection is paramount here. Avoid excessive traction or direct pressure on the nerve. Use vessel loops for identification and gentle retraction. Any previous surgery might have altered its anatomical course, so be prepared for variations.

3. Deep Exposure: The Extensile Köcher Approach

"We'll perform our deep exposure through an extensile Köcher approach. This gives us excellent access to the lateral and posterior aspects of the joint. We'll start by identifying the interval between the anconeus and the extensor carpi ulnaris."

• Surgical Directive: Identify the interval between the anconeus and the extensor carpi ulnaris. Elevate the anconeus and triceps off the posterolateral capsule.
• Anatomy: The Köcher approach utilizes the interval between the anconeus muscle (innervated by the radial nerve) and the extensor carpi ulnaris. The anconeus originates from the lateral epicondyle and inserts onto the lateral side of the olecranon and posterior ulna. The triceps tendon will be deep to this.
  

  
  
  

TECH FIG 1 • A. Extensile Köcher approach to the lateral elbow. The anconeus and triceps are elevated off the posterolateral capsule while the common extensor group is elevated off the anterior capsule. Exposure can be extended posteriorly with partial release of the triceps from the lateral aspect of the olecranon.

"Next, we need to mobilize the common extensor group. We'll release it from the anterior capsule and proximally with the extensor carpi radialis longus. This will give us access to the anterior compartment."

• Surgical Directive: Elevate the common extensor origin from the lateral epicondyle and the anterior capsule.
• Anatomy: The common extensor origin attaches to the lateral epicondyle and includes the extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris. The extensor carpi radialis longus originates more proximally from the supracondylar ridge.

"To fully expose the joint, we must isolate the lateral ulnar collateral ligament (LUCL) and release it from its humeral origin. This is a critical step for joint distraction and visualization. Following this, perform a comprehensive anterior and posterior capsular release."

• Surgical Directive: Identify the LUCL, which originates from the lateral epicondyle. Carefully incise its humeral attachment. Then, perform a thorough release of the anterior and posterior joint capsules.
• Anatomy: The LUCL is part of the lateral collateral ligament complex and is a primary stabilizer against varus stress and posterolateral rotatory instability. Its release allows for significant distraction and external rotation of the ulna relative to the humerus.
• Technique: Supination of the forearm allows the ulna to be rotated away from the humerus, further opening the joint.
• Pearl: Attempt to leave the medial collateral ligament (MCL) intact if at all possible. Its preservation will significantly improve postoperative stability, especially in valgus.
  

  
  
  

TECH FIG 1 • (continued) B. Deep extensile exposure requires release of the lateral collateral ligament and anterior and posterior capsule.

4. Expanding the Exposure: The TRAP Approach (If Needed)

"If we require even more extensile exposure, we can expand our Köcher approach into a triceps-reflecting anconeus pedicle, or TRAP, approach. This modification provides unparalleled access to the distal humerus while preserving the anconeus's neurovascular supply."

• Surgical Directive: For the TRAP approach, the triceps is reflected from medial to lateral off the olecranon in continuity with the anconeus. The medial interval is developed along the medial triceps proximally and between the anconeus and flexor carpi ulnaris distally. The lateral interval is an extensile Köcher approach between the anconeus and the extensor carpi ulnaris, extended proximally along the lateral supracondylar column.
• Anatomy: The TRAP approach maintains the neurovascular pedicle to the anconeus from above, ensuring its viability while allowing extensive exposure. This is a key advantage over a simple triceps splitting or osteotomy approach.
  

  
  
  

5. Articular Surface Assessment and Reshaping

"Now that we have excellent visualization, inspect the cartilage surfaces. If more than 50% of the articular surface is involved with degeneration, as is the case here, we proceed with the interposition arthroplasty."

• Surgical Directive: Reshape the distal humerus to conform smoothly to the olecranon. Remove all remaining cartilage from the distal humerus.
• Technique: Use a small osteotome, curette, or high-speed burr. The goal is to create a smooth, congruent surface for the interposition graft.
• Pearl: Avoid aggressive resection of bone. We need to retain as much subchondral bone as possible for structural support of the interposition membrane. This is critical for long-term graft survival and stability.
  

  
  
  

*TECH FIG 1 • (continued) E. The remaining cartilage on the distal humerus is removed and the subchondral bone is reshaped. Care should be taken to retain as much subchondral bone

Additional Intraoperative Imaging & Surgical Steps

REFERENCES

Causes of increased complications include:

• Multiple previous surgeries

• Blaine TA, Adams R, Morrey BF. Total elbow arthroplasty after interposition arthroplasty for elbow arthritis. J Bone Joint Surg Am 2005;87A:286–292.

• Cheng SL, Morrey BF. Treatment of the mobile, painful arthritic elbow by distraction interposition arthroplasty. J Bone Joint Surg Am 2000;82A:233–238.

• Figgie MP, Inglis AE, Mow CS, et al. Salvage of non-union of supracondylar fracture of the humerus by total elbow arthroplasty. J Bone Joint Surg Am 1989;71A:1058–1065.

• Figgie HE III, Inglis AE, Ranawat CS, et al. Results of total elbow arthroplasty as a salvage procedure for failed elbow reconstructive operations. Clin Orthop Relat Res 1987;219:185–193.

• Inglis AE, Inglis AE Jr, Figgie MM, et al. Total elbow arthroplasty for flail and unstable elbows. J Shoulder Elbow Surg 1997;6:29–36.

• Kamineni S, O’Driscoll SW, Urban M, et al. Intrinsic constraint of unlinked total elbow replacements: the ulnotrochlear joint. J Bone Joint Surg Am 2005;87A:2019–2027.

• Larson AN, Morrey BF. Interposition arthroplasty with an Achilles tendon allograft as a salvage procedure for the elbow. J Bone Joint Surg Am 2008;90A:2714–2723.

• Moro JK, King GJ. Total elbow arthroplasty in the treatment of posttraumatic conditions of the elbow. Clin Orthop Relat Res 2000;370:102–114.

• Morrey BF. Surgical exposures of the elbow. In: Morrey BF, SanchezSotelo J, eds. The Elbow and its Disorders, 4th ed. Philadelphia: Saunders Elsevier, 2009:115–142.

• Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 1981;63A:872–877.

• Morrey BF, Schneeberger AG. Total elbow arthroplasty for posttraumatic arthrosis. AAOS Instr Course Lect 2009;58:495–504.

• Nolla J, Ring D, Lozano-Calderon S, et al. Interposition arthroplasty of the elbow with hinged external fixation for post-traumatic arthritis. J Shoulder Elbow Surg 2008;17:459–464.

• O’Driscoll SW. The triceps-reflecting anconeus pedicle (TRAP) approach for distal humeral fractures and nonunions. Orthop Clin North Am 2000;31:91–101.

• Ramsey ML, Adams RA, Morrey BF. Instability of the elbow treated with semiconstrained total elbow arthroplasty. J Bone Joint Surg Am 1999;81A:38–47.

• Schneeberger AG, Adams R, Morrey BF. Semiconstrained total elbow replacement for the treatment of post-traumatic osteoarthrosis. J Bone Joint Surg Am 1997;79A:1211–1222.

• Wolfe SW, Ranawat CS. The osteo-anconeus flap: an approach for total elbow arthroplasty. J Bone Joint Surg Am 1990;72A: 684–688.

• Deformity of the elbow requiring realignment of the extremity through the implant

COMPLICATIONS Interposition Arthroplasty
- Complications of interposition arthroplasty include:

• Instability

• Infection

• Ulnar neuropathy

• Resorptive bone loss

• Heterotopic bone formation

• Complications related to the external fixator include:

• Superficial pin tract infections

• Deep infection (osteomyelitis)

• Pin breakage

• In the literature, complications have been reported to occur in up to 25% of patients.

Total Elbow Replacement
- TEA for traumatic conditions is associated with a high complication rate. Major complications include:

• Infection

• Current reports indicate an infection rate of 2% to 5% for primary TEA.

• Higher infection rates are noted with posttraumatic arthritis and a history of prior surgery.

• Loosening

• Triceps insufficiency (an underrecognized problem)

• Neurologic injury (incidence of transient ulnar neuropathy as high as 26% and permanent nerve injury up to 10%)

• Wound complications

• Associated with prior surgery

• Manage wound by immobilizing in extension postoperatively; use a subcutaneous drain to avoid hematoma formation. A significant postoperative hematoma should be evacuated.

• Periprosthetic fracture (can occur intraoperatively or postoperatively; incidence ranges from 1% to 23%)