UIC ORTHOPAEDIC SURGERY

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UIC ORTHOPAEDIC SURGERY

• GRAND ROUNDS
• 10-14-00
• RHEUMATOID ELBOW

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HISTORY

• 56 y/o hispanic female with history of rheumatoid
  arthritis
• Not currently employed, but previous worked as
  housekeeper and would like to return.
• Right hand dominant
• Complaint of long history of right elbow pain
  unresponsive to medical modalities and difficulty
  with use in ADLs
• EXTREMELY FRUSTRATING

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PHYSICAL EXAM

• 56 y/o appears stated age in NAD or discomfort
• RUE No gross angular deformities or skin
  abnormalities
• Carrying angle 10 degrees of valgus
• F/E -20 to 85 degrees
• S/P 60 and 50 degrees

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PHYSICAL EXAM

• Pain throughout all ROM and instability to varus
  and valgus stress at all degrees of flexion.
• Minimal wrist involvement, however, not as
  painful and disabling as elbow
• Strong radial pulse/brisk cap refill
• Neurologically intact throughout.

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AP right elbow
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Lateral right elbow
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SUMMARY

• 56 year old rheumatoid patient
• PAINFUL/UNSTABLE DOMINANT ELBOW
• UNRESPONSIVE TO CONSERVATIVE MANAGEMENT (MEDICAL)
• VERY FRUSTRATED WITH INABILITY TO USE RUE IN ADLS

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ADULT ONSET RHEUMATOID ARTHRITIS

• Chronic, systemic inflammatory disease
• Most often involving small joints of hands and
  feet, although any synovial joint may be
  affected.
• Dx Primarily clinical, although autoantibodies
  to IgG may be found in the blood.

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ARA CRITERIA (revised 1987)

• -Morning stiffness
• -Arthritis of 3 or more areas
• -Arthritis of hand joints
• -Symmetrical arthritis
• -Rheumatoid nodules
• -Serum factor
• -Xray changes

• -last at least 1 hour
• -14 possible areas, observed by MD
• -at least 1 area in hand
• -Simultaneous involve
• -Subcutaneous nodules
• -abnormal amount serum RF
• -Erosions, bony decalcification most marked
  adjacent to joint.

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RHEMATOID ARTHRITIS

• EXACT CAUSE UNKNOWN
• UNDERSTANDING OF NATURE AND PATHOGENESIS OF
  DISEASE HAS INCREASED, NOW ATTACK AT MULTIPLE
  LEVELS BOTH MEDICALLY AND SURGICALLY./

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RHEUMATOID ARTHRITIS

• SURGERY SHOULD ACCOMPLISH
• RELIEVE PAIN
• PREVENT DESTRUCTION OF CARTILEGE OR TENDON
• IMPROVE FUNCTION OF JOINT
• CORRECT DEFORMITY

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RHEUMATOID ELBOW

• ELBOW IS AFFECTED IN 50 OF RHEUMATOID PATIENTS
• COMPARED WITH HIP/KNEE UNCOMMON TO BECOME SO
  DISABLED AS TO REQUIRE SURGERY

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RHEUMATOID ELBOW

• WHEN ELBOW AFFECTED SO SEVERELY THAT SURGICAL
  INTERVENTION REQUIRED, FUNCTIONAL OUTCOMES OF
  PROCEDURES OTHER THAN TEA HAS BEEN POOR.
• Dickenson (JBJS 1976)
• Gendi (JBJS 1997)

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ALGORITHM TREATMENT OF THE RHEUMATOID ELBOW
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TEA HISTORY

• 1st TEA performed in 1972 by Dee
• Many surgeons prior to this designed custom
  hemiarthroplasties
• Nylon, rubber, acrylic, steelmost limited
  motion, loosened.

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TEA History

• Final effort prior to true TEA was an articular
  resurfacing prosthesis
• Example Street and Stephens convex capitellum
  and trochlea

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TEA HISTORY

• Peterson and Bickel saddle for proximal ulna
  (1971)

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INDICATION FOR TEA

• PAIN
• RANGE OF MOTION
• INSTABILITY

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IMPLANT SELECTION

• BASED UPON 3 FACTORS
• EXTENT OF DISEASE PROCESS
• SPECIFIC NEED OF PATIENT
• EXPERIENCE OF SURGEON
• CONTROVERSIES UNLINKED VS. SEMICONSTRAINED..

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TOTAL ELBOW IMPLANTS
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HISTORY OF MODIFICATIONS
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Modifications
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EXAMPLE OF MODIFICATIONS

• THE MEDIAL AND LATERAL EPICONDYLES ARE NOT
  NECESSARY FOR STABILITY SECONDARY TO ANTERIORLY
  PLACED FLANGE.

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Right elbow-dislocated
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Distal humerus
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HUMERAL PREPARATION
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HUMERAL PREPARTATION
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PLACEMENT OF HUMERAL PROSTHESIS WITH BONEGRAFT
UNDERLYING FLANGE
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COONRAD-MORREY HUMERAL PROSTHESIS
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HUMERAL PROSTHESIS
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PROXIMAL ULNAR PRESENTATION
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PROXIMAL ULNAR PREPARATION
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ULNAR COMPONENT PLACEMENT
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ULNAR COMPONENT
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ARTICULATION OF COMPONENETS
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Coonrad-Morrey- flexion
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Coonrad-Morrey - extension
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Lateral with new prosthesis
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AP new prosthesis
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RESULTS

• Gill, DR Morrey, BF (JBJS 1998)
• 10 to 15 year follow up study
• 78 elbows gtgt86 good/excellent result
• Ewald, FC (JBJS 1993)
• 202 elbows at mean of 69 months
• Kraay, MJ (JBJS-British 1994)
• 90 survivorship of 113 semiconstrained TEA

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COMPLICATIONS

• ASEPTIC LOOSENING
• ULNAR NERVE INJURY
• TRICEPS AVULSION
• INFECTION
• FRACTURE (Intraop vs. Postop)