Joint Surgery and Postoperative

Management

The most common fracture in the elbow region is a fracture of the head

and neck of the radius.

Accounts for approximately one-third of all elbow fractures.

Usually occurs when a person falls on an outstretched hand when the elbow

is extended, causing a posterior dislocation and fracture of the radial head

coupled with injury of elbow ligaments.

The goals of surgery of the elbow joint

complex and postoperative rehabilitation

(1) Relief of pain

(2) Restoration of boney alignment and joint stability

(3) Sufficient strength and ROM to allow functional use of the elbow and

upper extremity

Open Reduction and Internal Fixation

■ Advantages:

Achieves stabilization and fixation of multiple fracture fragments with normal or near-normal alignment.

Ability to repair significant ligamentous damage

Early postoperative motion permissible unless reconstruction of ligaments required

■ Disadvantages:

Extensive soft tissue disruption and arthrotomy required

Less practical than radial head excision for severely comminuted fractures

Arthroscopic or Arthroscopically Assisted

Reduction and Internal Fixation

Advantages:

Allows arthroscopic evaluation of the joint and débridement of fracture debris

if fully arthroscopic, less soft tissue disturbance, less postoperative pain and better

cosmetic outcome

Disadvantages:

Limited to reduction and fixation of no more than two-part displaced fractures

Not appropriate for radial neck fractures

Excision of the Radial Head

■ Advantages

Only option for severely comminuted, non-reconstructible fractures

fragments or internal fixation; early ROM permissible

■ Disadvantages

Requires arthrotomy

may compromise joint stability if a prosthetic implant is not used

Severity of Elbow Joint Disease and

Selection of Surgical Procedure

Radial Head Excision or Arthroplasty

Indications for Surgery

■ Severely comminuted fracture or fracture-dislocations of the head or neck of

the radius that cannot be reconstructed and stabilized with internal fixation.

■ Chronic synovitis and mild deterioration of the articular surfaces associated

with arthritis of the HR and proximal RU joints resulting in joint pain.

CONTRAINDICATIONS:

• Radial head excision is contraindicated in the growing child.

• Excision without replacement of the radial head is not an appropriate option

in the presence of a damaged lateral ulnar collateral ligament complex.

• Arthroplasty also is contraindicated with active infection

Procedure

Selection of procedure

Depending on the integrity of the ligaments and stability of the elbow

complex, a radial head excision may be selected

Or

implant Arthroplasty may be the better choice.

The use of a prosthetic implant is indicated when there is clinical instability

of the elbow as the result of disruption of the supporting ligaments

Implant designs, materials, and fixation.

• Radial head implants originally were flexible and made of silicone. However,

this material is no longer used because it has been associated with

inflammatory arthrosis (synovitis) of the HU joint.

• Currently used implants are one-piece or two piece (modular) designs that

more closely replicate the normal biomechanics of the elbow and are made

of metal, ceramics, or ultra-high molecular weight polyethylene.

• The use of pyrolytic carbon as an implant material also is being investigated.

• However, the optimal radial head implant has yet to be designed and

fabricated.

• Cemented or cementless fixation is an option with total elbow arthroplasty

Overview of Operative Procedure

• A lateral or posterolateral triceps-sparing incision at the elbow and forearm is made

into the joint (arthrotomy) just anterior to the lateral collateral ligament.

• The radial head is exposed, and a radial osteotomy is performed at the level of the

annular ligament to resect the head.

• For a severe fracture, some of the neck of the radius also may need to be excised.

When exposing the operative field, effort is made not to detach intact ligaments.

• A concomitant synovectomy is done if proliferative synovitis is present (typically

seen in RA and JRA).

Complications

• Damage to the posterior interosseous nerve is a concern during surgical

excision of the radial head.

Postoperatively complications of excision with or without implant may

include delayed wound closure, infection, limited ROM of the elbow and/or

forearm, persistent pain, and a sense of instability.

Postoperative Management

• The goals and interventions

• The rate of progression,

• Length of the rehabilitation program,

• Final outcomes,

Are highly dependent on the extent of damage to soft tissues from injury or

chronic inflammation, and response to treatment.

Postoperative Management

Immobilization

The elbow is immobilized in a well-padded posterior resting splint in a position of 90° of flexion and mid-position of the forearm.

When elbow motion is permissible (1 to 3 days after surgery or longer) the splint is removed for exercise but is replaced after exercise and worn at night for an extended period of time to protect healing tissues.

If the stability of the elbow is in question, the patient may need to wear a dynamic (hinged) splint for ROM exercises.

Exercise: Maximum Protection Phase

Goals and interventions.

First 6 weeks after surgery, focuses on

• Patient education that emphasizes wound care, control of pain and

peripheral edema, and exercises to offset the adverse effects of

immobilization

• The arm is elevated for comfort and to control edema distally.

Maintain mobility of un-operated joints.

Maintain mobility of the elbow and forearm.

Minimize muscle atrophy.

Exercise: Moderate and Minimum

Protection Phases

• To restore nearly full or at least sufficient ROM for functional activities while

maintaining stability of the elbow.

• Exercises to improve upper extremity strength and muscular endurance and

use of the involved elbow for light functional activities

Increase ROM

■ Gentle manual stretching, hold-relax techniques or self-stretching

■ Grade II joint mobilization techniques initially, followed by grade III

mobilizations after 6 weeks when the joint capsule is well healed

CONTRAINDICATION:

• Do not perform valgus/varus stretches in terminal extension/flexion, particularly if the radial head was not replaced with a prosthetic implant or if the integrity of the supporting ligaments and stability of joints are questionable.

• Low-load, long-duration, dynamic splinting or alternating use of static splints in maximum flexion and extension

Improve functional strength and muscular endurance.

■ Low-load resistance exercises (maximum 1 to 2 lb), emphasizing high repetitions

■ Use of the operated upper extremity for light ADL

Resumption of recreational and work-related activities.

• A patient must permanently refrain from high-impact activities

And

• Participating in recreational activities that impose significant stress across the

elbow complex, such as racquet sports.

Total Elbow Arthroplasty

• A treatment option primarily for the older individual with debilitating, late-

stage elbow arthritis.

• TEA now is considered a preferred surgical alternative to open reduction and

internal fixation for management of severely comminuted, intra-articular

distal humeral fractures sustained by elderly patients.

Indications for Surgery

Debilitating pain and loss of functional use of the upper extremity

Gross instability of the elbow

Acute comminuted, intra-articular fracture and nonunion fracture of the

distal humerus

Failed interposition arthroplasty or radial head resection

Marked limitation of motion of the elbows

Contraindications to Total Elbow

Arthroplasty

Absolute

• The presence of active infection

• Neurological dysfunction leading to paralysis and inadequate control of elbow musculature

Relative

• History of previous elbow infection

• Irreparable supporting ligaments

• Insufficient bone stock

• The younger patient, particularly one who must lift heavy loads (>10 lb) after TEA

Procedure

• Implant design and selection considerations. Early designs were hinged

allowed only flexion and extension of the elbow joint. joint dislocation were

common complications.

• At present, an arc of flexion and extension, contemporary designs provide

5° to 10° of varus and valgus and a small degree of rotation

• The designs of total elbow replacement can be

classified into two broad categories: linked

(articulated) and unlinked (non-articulated).

• Rather than being fully constrained, as the early

components were, linked humeral and ulnar implants

are now loosely constrained, referred to as

semiconstrained designs.

• Linked designs derive inherent stability from

one or two pins, which couple the humeral and

ulnar components.

• In addition, semiconstrained designs enhance

joint stability and decrease the risk of posterior

dislocation.

• Overall, linked designs, because of their inherent stability,

are considered appropriate for use with a broader

spectrum of patients, including those with unstable

elbows, than unlinked designs.

• Designs classified as unlinked are composed of two

separate, non-articulated implants and are often called

resurfacing replacements.

Procedure

• A longitudinal incision is made at the posterior aspect of the elbow, either

slightly lateral or medial to the olecranon process. The ulnar nerve is isolated

and protected throughout the procedure.

• The distal attachment of the triceps is detached and reflected laterally with a

triceps-reflecting approach or split longitudinally and retracted along the midline

with a triceps-splitting approach.

• The available ROM and stability of the prosthetic joint are checked intra-

operatively and x-rays are taken to confirm proper alignment of the implants.

• The components are then cemented in place, and the capsule and ligaments

are repaired

• Careful placement of the ulnar nerve in a subcutaneous pocket, the incision

is closed, and a sterile compressive dressing and posterior and/or anterior

splint are applied to immobilize the elbow and forearm.

• The arm is elevated to control peripheral edema.

Complications

Intraoperative complications.

Fracture and component mal-positioning, can significantly affect short- and

long-term outcomes.

Ulnar damage or irritation, either transient or permanent, also can occur

intra-operatively

Postoperative complications.

Deep infection.

Joint instability

Wound healing problems

Triceps insufficiency

Postoperative Management

Immobilization

• A well padded posterior or anterior splint is used to immobilize the elbow

and maintain stability and protect structures

• Recommendations for the positions and duration of immobilization vary

Position.

The position of immobilization is based on a number of factors, including the

surgical approach, the implant design, and which soft tissues were repaired and

require protection.

• For example, a triceps-reflecting approach was used for a linked TEA, full or

almost full elbow extension typically will be selected to protect the reattached

triceps tendon and a neutral position of the forearm.

• In contrast, with an unlinked TEA, which requires repair of the lateral

ligament complex the position of immobilization is a moderate degree of

flexion to lessen stress on the repaired ligaments.

• If a patient had a significant preoperative elbow flexion contracture that was

surgically released, an anterior splint may be selected with the elbow placed

in the available amount of extension.

• An extended position is also indicated if symptoms of ulnar neuropathy are

present to alleviate pressure in the cubital tunnel

Duration.

• The period of continuous immobilization varies, ranging from 1 to 2 days to

several weeks.

• This time period depends on the design of the prosthesis, the surgical

approach, the integrity of ligamentous structures,

• Unlinked/resurfacing designs, which have little inherent stability, require a

longer period of immobilization than linked/semiconstrained designs

Exercise: Maximum Protection Phase

• The focus during the first phase of rehabilitation, which extends

approximately over a 4-6 week period, includes control of inflammation,

pain, and edema with use of medication as needed, application of cold and

regular elevation of the operated arm.

• Early ROM exercises to offset the adverse effects of immobilization

Goals and interventions.

Maintain mobility of the shoulder, wrist, and hand

Regain motion of the elbow and forearm.

Minimize atrophy of upper extremity musculature.

Exercise: Moderate and Minimum

Protection Phases

• By about 4 to 6 weeks postoperatively, soft tissues have healed sufficiently to

withstand increasing stresses.

• By 12 weeks only minimum protection is necessary; therefore, a patient

typically can resume most functional activities.

Goals and interventions.

• The focus of rehabilitation during the intermediate and final phases is to

improve ROM.

• These goals must be reached without disrupting repaired soft tissues and

compromising the stability of elbow.

• Strength and muscular endurance usually continue to improve up to 6 to 12

months postoperatively by cautious use of the operated arm for functional

activities.

Increase ROM of the elbow.

• Low-intensity, manual self-stretching.

• Low-load, long-duration dynamic splinting

PRECAUTIONS:

Emphasize end-range extension before end range flexion to protect the posterior capsule and the triceps mechanism.

• If symptoms of cubital tunnel syndrome are present avoid prolonged or repeated end-range positioning or stretching to increase elbow flexion

Regain functional strength and muscular endurance of the operated extremity

• Resisted, multiple-angle isometric exercises at 5 weeks if not initiated previously.

• Performed light ADL initially (<1 lb of weight)

• If a triceps-reflecting approach was used, modify activities to avoid those that require lifting with the elbow extended and pushing motions, such as pushing up from a chair or using a walker, axillary crutches, or a cane.

• Dynamic, open-chain resistance exercises no earlier than 6 weeks and

often later using a light-weight (1 lb) or light-grade elastic resistance.

Emphasize gradually increasing repetitions rather than resistance.

• Repetitive lifting during exercise and functional activities limited to 1 lb for

the first 3 months and 2 lb for the next 3 months.

• Permanently limit repetitive lifting to no more than 5 lb and a single lift to

no more than 10 to 15 lb.

• Low-load, closed-chain activities, such as wall push-ups after 6

weeks or later

• Upper extremity ergometry.

• High-load PRE, heavy lifting during home- and work-related

activities, and recreational activities that place high-loads or impact

on the upper extremities (e.g., racquet and throwing sports or golf)

are not allowed after TEA.