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.
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