Total Elbow Arthroplasty For Recurrent Elbow Dislocation

Tun Lin FOO, Kee Yuan NGIAM, Choon Hin LAI

Department of Orthopaedic Surgery
Tan Tock Seng Hospital, Singapore

Address for Correspondence:
Tun Lin Foo
Department of Orthopaedic Surgery
Tan Tock Seng Hospital
11 Jalan Tan Tock Seng Hospital
Singapore 308433

Fax    : +65 63577715
Phone: +65 63577713 
E-mail: tun.foo@gmail.com

Abstract:

Recurrent elbow dislocation is rare in the absence of associated fracture.  Treatment for chronic elbow instability is usually ligamental reconstruction.  We present a previously unreported indication of total elbow arthroplasty in a case of recurrent elbow dislocation in an elderly lady.  She had excellent results at two year follow up.  The rationale for this new indication is discussed.

J.Orthopaedics 2009;6(3)e8

Keywords:

elbow dislocation; total elbow

Case history:

A 69 year-old female with history of rheumatoid arthritis, epilepsy, and Parkinson’s     disease presented with a posterior dislocation of her right elbow after a fall (figure I).  No associated fractures were detected on orthogonal radiographs of the elbow.  Clinically, there was no evidence of neurovascular compromise before and after reduction.  Post reduction radiographs showed a well-reduced joint with no associated fractures.  As such, her elbow was immobilized at 90 degrees.  One week after injury, the range of motion at the elbow was limited by her apprehension.  Her arc of movement was between 10 to 90 degrees after three weeks of immobilization.  She underwent physiotherapist supervised elbow mobilization, and managed to achieve full range of motion, two months later.

Subsequently, she sustained two further dislocations as a result of falls, both required manipulative reduction.  Her main complaints were severe pain, instability, crepitus and limitation in performing her activities of daily living.   Clinically, her elbow was grossly unstable, and was easily dislocated.  There were no manifestations of rheumatoid arthritis in her elbow, although she did have a mild degree of metacarpophalangeal subluxation, and ulnar deviation of her fingers. The calculated Mayo Elbow Performance Score¹ was 15.  In view of her symptoms and medical problems, she was offered total elbow arthroplasty.

Fig. 1 Initial radiographs showing dislocation

The procedure was performed under general anaesthesia via Bryan’s approach by the senior author (CHL).  There was marked attenuation of the medial and lateral collateral ligament complexes and a moderate amount of chronic synovitis was present.  A Coonrad-Morrey semi-constrained total elbow prosthesis (Zimmer, Warsaw, IN, USA) was inserted and cemented (Simplex, Howmedica, Limerick, Ireland) with a third generation cementing system.  Gentle physiotherapy was commenced on the third postoperative day and continued for the next few weeks.  She recovered uneventfully from the surgery and at three months post op, she was able to resume her activities of daily living independently (Figure 2 post operative radiograph).  Her Mayo Elbow Performance Score was 95.  Two years on, she had 10 to 140 degrees of flexion, and prono-supination of 70/70. 

Fig. 2 Post operative radiograph

Discussion :

Recurrent elbow dislocation is rare in the absence of associated fracture².  Following reduction and early range of motion exercises, the majority of elbow dislocations remain stable³.   Most cases of chronic elbow instability is attributed to injury of the lateral collateral ligament complex. Medial elbow instability is usually associated with throwing athletes⁴.  Chronic elbow instability does not improve over time.  In the symptomatic patient, surgery is justified.  Surgical treatment for chronic elbow instability without associated fractures is reconstruction of the lateral collateral ligament complex with tendon grafts^{5, 6, 7}.  Authors have reported using palmaris longus, semitendinosus, plantaris, triceps fascia, and strips of tendo Achilles as tendon autografts.  The remaining attenuated soft tissue may be imbricated to increase the lateral capsular tightness and strengthen the repair.  Complications of reconstruction include delayed laxity, redislocation, and donor site morbidity.  Thus far, we are not aware of total elbow arthroplasty being indicated in recurrent dislocations, or as a salvage procedure for failed soft tissue reconstruction procedure in elbow instability.  The demographics of patients, being younger, would account for this.  However, there might be a role for total elbow arthroplasty in the elderly patient with lower functional demand who suffers from chronic elbow instability or dislocations. 

The co-existing rheumatoid arthritis in our patient strengthens the case for arthroplasty.  Long-term corticosteroid therapy impairs tissue and wound healing.  Disease activity in the elbow may erode and destroy the soft tissue reconstruction, rendering the elbow unstable, and subsequently requiring a revision surgery.  A semi-constrained total elbow arthroplasty is able to provide elbow stability without the potential complications associated with ligamental reconstruction. General consensus⁸ for cut-off age is 60, although in rheumatoid patients who suffer from debilitating arthritis, the age limit is reduced to 30.  The semi-constrained Coonrad-Morrey prosthesis has favorable long-term results^{9, 10, 11, 12}.  Alridge et al reports functional success in 50% of cases 10-14 years post op, and 25% at 15-19 and 20-31 years.  The complications of total elbow arthroplasty include aseptic loosening, septic arthritis, peri-prosthetic fractures, and polyethylene bushing wear.  Early implant failure is associated with lifting objects more than 10lb or repetitive lifting greater than 2lb⁸.

Conclusion:

In elderly patients who suffer from recurrent dislocations and chronic instability, total elbow arthroplasty provides stability and symptomatic relief.  The co-existence of arthritis – RA, OA, etc. with instability makes a patient a suitable candidate for arthroplasty.  The caveat: patient must accept the limitation of the implant.

Reference :

1. Morrey BF, An KN, Chao EYS.  Functional evaluation of the elbow. In The Elbow and Its Disorders, edited by B. F. Morrey. Ed. 2, Philadelphia, W. B. Saunders, 1993

2. Duckworth AD, Ring D, Kulijdian A, et al.  Unstable elbow dislocations.  J Shoulder Elbow Surg 2008; 17(2): 281-286

3. Mehlhoff TL, Noble PC, Bennett JB, Tullos HS.  Simple dislocation of the elbow in the adult. Results after closed treatment.  J Bone Joint Surg Am 1988; 70A: 244-249

4. Grace SP, Field LD.  Chronic Medial Elbow Instability.  Orthop Clin N Am 2008; 39: 213-219

5. Nestor BJ, O'Driscoll SW, Morrey BF. Ligamentous reconstruction for posterolateral instability of the elbow. J Bone Joint Surg 1992:74A:1235-1241

6. Sanchez-Sotelo J, Morrey BF, O’Driscoll SW.  Ligamentous repair and reconstruction for posterolateral rotatory instability of the elbow.  J Bone Joint Surg Br 2005; 87-B: 54-61

7. Lee BPH, Teo LHY.  Surgical reconstruction for posterolateral rotatory instability of the elbow.  J Shoulder Elbow Surg 2003; 12: 476-479

8. Gallo RA, Payatakes A, Sotereanos DG.  Surgical options for the arthritic elbow.  J Hand Surg 2008; 33A: 746-759

9. BF Morrey, Adams RA. Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow.  J Bone Joint Surg Am 1992; 74: 479-490

10. Gill DRJ, Morrey BF.  The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis.  A ten to fifteen year follow-up study.  J Bone Joint Surg Am 1998; 80: 1327-1335

11. Little CP, Graham AJ, Karatzas G, et al.  Outcomes of total elbow arthroplasty for rheumatoic arthritis: comparative study of three implants.  J Bone Joint Surg Am 2005; 87: 2439-2448

12. Aldridge JM III, Lightdale NR, Mallon WJ, et al.  Total elbow arthroplasty with the Coonrad/Coonrad-Morrey prosthesis.  A 10 to 31 year survival analysis.  J Bone Joint Surg Br 2006; 88: 509-514.

This is a peer reviewed paper 

Please cite as: Tun Lin Foo: Total Elbow Arthroplasty For Recurrent Elbow Dislocation

J.Orthopaedics 2009;6(3)e8

URL: http://www.jortho.org/2009/6/3/e8

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