Linked Elbow Arthroplasty: Rationale, Indications, and Surgical Technique

Published on 11/04/2015 by admin

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CHAPTER 53 Linked Elbow Arthroplasty: Rationale, Indications, and Surgical Technique

INTRODUCTION

As noted in Chapter 52 and further described in Chapters 54 through 60, the results of total elbow arthroplasty are improving with increased basic knowledge of elbow mechanics,24 better designs, and greater surgical experience.21 The general principles of the surgical technique and improved designs2,9,14,18,24 and a detailed description of my specific method of inserting the Coonrad-Morrey implant are presented. The results of semiconstrained joint replacement arthroplasty emphasize the Mayo Clinic experience with the modified Coonrad device.

RATIONALE

The selection and the rationale for unlinked elbow replacement are described in Chapter 52. The reason for continuing to use a semiconstrained linked implant is simple: the current design works well, is reproducible, and can address a broad spectrum of pathology. The Coonrad-Morrey linked device and similar implants are distinctly different, both conceptually and clinically, from the original, fully constrained articulated devices. In today’s linked prostheses, the one feature in common is that the ulnar component is coupled to the humerus with angular and rotatory laxity of 5 to 10 degrees (Fig. 53-1). The theoretical advantage has been confirmed in the laboratory in which it was demonstrated that the articulation tracks within the limits of its tolerance (Fig. 53-2). This decreases stresses on the bone-cement interface.24 Documentation of improved clinical results attests to the effectiveness of the semiconstrained linked design.2,4,13,14,16,18,21 Of particular note is that the linked implant dramatically broadens the indications for reconstructive surgery of the elbow. Whereas unlinked devices may be very effective for rheumatoid arthritis, the potential for instability limits their use when deformity and osseous and ligamentous deficiency is present. The linked implant may be used with equal effectiveness in patients with rheumatoid arthritis,20 for post-traumatic arthrosis,19 and for revision surgery.18 The enhanced stability supplied by the coupling is provided without transmission of excessive stress to the bone-cement interface with the semiconstrained design.24

PRINCIPLES OF SURGICAL TECHNIQUE

One of the most important factors in the improved results of elbow joint replacement in the past and particularly with those being developed is improved surgical technique. Here, we describe our current technique.

THE ULNAR NERVE

Opinions are divided with respect to the management of the ulnar nerve. Some surgeons believe that it should not be exposed,7,9,12,16,27 whereas today most believe that the ulnar nerve should be directly visualized and moved as an integral part of the surgical approach and procedure.4,10,15,23 We favor the latter philosophy.

THE TRICEPS

The fascial tongue exposure of Campbell (Van Gorder) causes a good deal of soft tissue dissection, with a significant amount of dead tissue that provides an environment favorable to infection, which may result in weakness.5,22 Splitting the triceps in the midline is enjoying a resurgence of popularity. In our experience, this tends to cause detachment of the medial insertion. Therefore, I continue to prefer the Mayo technique of reflecting the triceps in continuity with the ulnar periosteum and forearm fascia described by Bryan and Morrey.5 The important point, however, is a meticulous repair (see later).