Total elbow arthroplasty: outcomes after triceps-detaching and triceps-sparing approaches

doi:10.1016/j.jse.2014.11.038

Journal of Shoulder and Elbow Surgery

Volume 24, Issue 3, March 2015, Pages 339-347

https://doi.org/10.1016/j.jse.2014.11.038 Get rights and content

Background

Total elbow arthroplasty (TEA) is associated with high complication rates compared with other large-joint arthroplasties. The frequency and type of complication may differ, depending on the surgical approach. A comparison of outcomes with triceps-off and triceps-on approaches was investigated.

Methods

Seventy-three patients underwent 83 primary TEAs between 2003 and 2012. Forty-six elbows had a triceps-off approach, and 37 had a triceps-on approach. Results were reviewed at a mean of 4.2 years. Cementing technique was graded according to Morrey's criteria, and clinical outcomes were assessed by means of the Mayo Elbow Performance Score.

Results

There was no statistically significant difference between the triceps-off and triceps-on groups with regard to the patient's age, gender, preoperative Mayo Elbow Performance Score or range of motion, or previous surgery on the affected elbow. Among patients who underwent a TEA for an inflammatory arthropathy, there was a significant difference in outcome between groups with regard to final flexion, extension, arc of motion, and pronation. Cementing technique in the triceps-off group was adequate in 70%. In the triceps-on group, cementing technique was adequate in 92%. The complication rate in the triceps-off group was 32.6% and included 7 triceps ruptures. Three patients who had attempted repairs of the triceps rupture developed deep infections requiring multiple further surgeries. The complication rate in the triceps-on group was 8.1%.

Conclusion

A triceps-on approach in TEA results in consistently good clinical outcomes with no risk of triceps rupture, and the approach does not compromise the cement mantle. We believe that this approach will reduce complication rates in TEA.

Section snippets

Materials and methods

A list of all patients who underwent a TEA between 2003 and 2012 by the University of Cape Town Shoulder and Elbow Unit was obtained from a surgical database. These patients formed the study cohort, and their medical records and radiographs were reviewed. Exclusion criteria were revision TEAs and postoperative follow-up of <12 months. Data captured included patient demographics, range of motion preoperatively and at various stages postoperatively, surgical time, radiographic analysis of

Results

The cohort consisted of 62 women (9 bilateral) and 11 men (1 bilateral). The average age at surgery was 60 years (range, 24-89 years). Sixty TEAs were performed for an inflammatory arthropathy, 6 for acute fractures, 5 for post-traumatic osteoarthritis, 4 for hemophiliac arthropathies, 2 for distal humerus nonunions, 2 for failed internal fixations referred to our unit, 2 for primary osteoarthritis, 1 for an idiopathic arthropathy,⁴ and 1 for post-traumatic instability.

Duration of follow-up for

Discussion

In our cohort, the 15.2% incidence of triceps rupture in the triceps-detaching group is comparable to that of other studies that have assessed patients for this complication. Kelly et al¹² found an 11% incidence of triceps insufficiency in 28 TEAs performed for inflammatory arthropathies by a triceps-reflecting approach with bone slivers. They chose to manage these patients conservatively and reported good outcomes. Hildebrand et al¹¹ found an 8% incidence of triceps rupture in 39 TEAs by a

Conclusion

We believe that a triceps-on approach is the best way forward in TEA as it may eliminate the risk of triceps rupture, does not compromise cementing technique or duration of surgery, and results in a significant reduction in complication rates compared with the literature.

Disclaimer

The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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Cited by (49)

Recent advances in unlinked total elbow arthroplasty in Japan
2024, JSES International
Total elbow arthroplasty (TEA) is a valuable therapeutic approach for improving function and relieving pain in severely deformed elbow joints. However, TEA is associated with a high incidence of complications. In Japan, the use of unlinked TEA has a long history, with the development of the Kudo prosthesis marking a significant milestone. Subsequently, various unlinked implant designs have been developed. Although favorable long-term clinical results have been reported, complications remain a concern. To further improve the outcome of unlinked TEA, attempts have been made in recent years to develop various surgical approaches and intraoperative support devices. This review focuses on the clinical outcomes and recent advances in unlinked TEA in Japan.
A comprehensive review of clinical results and advancements in unlinked TEA in Japan was conducted. The analysis included trends in the number of TEA, medium-term and long-term results for unlinked TEA, surgical approaches, or preoperative planning techniques.
Several implant designs have been developed in Japan. Clinical studies have reported satisfactory long-term outcomes with these implants, but complications, such as infection, fractures, and dislocation, have been observed. In order to enhance the outcomes of unlinked TEA, various triceps-on approaches have been developed as alternatives to the triceps-detaching approach, which compromises the continuity between the triceps tendon and ulna, leading to inevitable complications related to the triceps tendon. Preservation or repair of the surrounding soft tissues is considered critical for preventing postoperative instability due to the absence of a radial head in the current unlinked TEA design. Computed tomography-based 3-dimensional preoperative planning has been pioneered in Japan, demonstrating its effectiveness in predicting implant size and achieving appropriate implant placement. Additionally, augmented reality–assisted surgery is being explored to accurately translate preoperative planning into the surgical procedure.
Unlinked TEA for inflammatory arthritis has exhibited promising long-term results in Japan, with ongoing efforts to improve surgical techniques and preoperative planning. Further advancements are anticipated to prevent complications such as dislocation and peri-implant fractures.
Revision Arthroplasty in the Challenging Elbow
2023, Hand Clinics
Comparison of clinical outcomes between the olecranon osteotomy approach and the Bryan-Morrey approach for total elbow arthroplasty
2023, Journal of Shoulder and Elbow Surgery
This study aims to investigate the clinical efficacy of the olecranon osteotomy approach and the Bryan-Morrey approach in total elbow arthroplasty (TEA).
In this retrospective study, 49 patients with elbow disease were treated with TEA. A total of 22 patients with TEA by olecranon osteotomy approach were designated as group A, and 27 patients with TEA by Bryan-Morrey approach were designated as group B. There were 22 males and 27 females, aged 32-82 years with a mean age of 62 years. There were 44 cases of unilateral elbow joint, including 27 cases on the left elbow and 17 cases on the right elbow, and 5 cases of the bilateral elbow joint. There were 6 cases of osteoarthritis (7 elbows), 18 cases of rheumatoid arthritis (22 elbows), 14 cases of traumatic arthritis (14 elbows), 7 cases of distal humeral fractures (7 elbows), and 4 cases of elbow tuberculosis (4 elbows). For each group, we recorded the operative time, intraoperative bleeding, elbow flexion, extension, pronation, supination, postoperative complication rates, and Mayo Elbow Performance Score after surgery.
Operative time and intraoperative bleeding were less in group A than in group B (53-120 min [70 (62.5, 78) min] vs. 64-105 min [77 (73, 87) min], and 10-200 ml [50 (20, 90) ml] vs. 5-250 ml [100 (50, 150) ml], P < .028). The elbow flexion, pronation activity, and Mayo Elbow Performance Score were higher in group A than in group B, [(121 ± 12)° vs. (112 ± 10)°, 85 (85,85)° vs. 80 (77,85)°, and (94 ± 3) points vs. (91 ± 4) points, P < .036], while elbow extension and supination activity and complication rates were not statistically significant in either group.
Compared to Bryan-Morrey approach, the olecranon osteotomy approach to TEA provides adequate visualization, saves operative time and reduces bleeding, provides better flexion activity, effectively improves elbow function, and achieves satisfactory clinical outcomes.
Biomechanical Evaluation of 2 Common Approaches for Total Elbow Arthroplasty: Triceps Tongue Compared With Triceps Reflecting
2023, Journal of Hand Surgery
We hypothesize that the triceps tongue approach will be equivalent in strength to the triceps reflecting approach in load to failure following a cyclic preload.
Seven paired fresh-frozen cadaveric arms were dissected using the triceps reflecting approach or triceps tongue approach to the posterior elbow. The triceps was then repaired in each specimen, and the elbows were placed in a testing jig. Elbows were preloaded in a cyclic fashion at 5 lbs (2.3 kgf) for 200 cycles in flexion/extension, followed by load to failure. The stiffness and ultimate failure strength for each specimen were determined. We defined ultimate failure as gapping in the suture construct of 4 mm or suture breakage.
One of the triceps tongue specimens was excluded due to a testing error, resulting in 6 elbows in this group. There were no tendon repair failures during the cyclic preload. The median ultimate failure of the reflecting group occurred at 65 pounds, compared to 115 pounds in the tongue group. This was significantly different. The reflecting approach consistently failed along the entire bone-tendon interface. The tongue approach failed at the proximal repair site in 4 of 6 specimens, while the longitudinal aspect of the tendon repair remained intact.
Following a cyclic preload of 5 lbs for 200 cycles, the triceps tongue repair is stronger than triceps reflecting in ultimate failure. The mode of failure of triceps tongue repair may be superior to that of triceps reflecting.
This study may help guide surgeons when choosing a “triceps off” approach to total elbow arthroplasty.
Histologic Evaluation of the Triceps Brachii Tendon Insertion: Implications for Triceps-Sparing Surgery
2022, Journal of Hand Surgery
Triceps detachment and olecranon osteotomy are 2 techniques used to enhance exposure in elbow surgery. Both the techniques can potentially add considerable morbidity and lengthen the recovery after surgery. Triceps-sparing surgery can potentially mitigate those issues. The purpose of this study was to evaluate the triceps tendon insertion at a histologic level to help improve triceps-sparing surgical techniques used in elbow trauma and arthroplasty.
Seventeen fresh-frozen cadaveric elbow specimens were collected. The olecranon and its soft tissue attachments were isolated. We performed gross measurements and sectioned the specimens for histologic evaluation in the saggital or coronal planes. The proximal-to-distal and medial-to-lateral dimensions of the tendon and the distance from the proximal tip of the olecranon to the proximal tendon insertion were measured microscopically on stained embedded sections.
The proximal-to-distal dimension of the triceps tendon insertion was less than previously reported, whereas the medial-to-lateral dimension was similar. The true distance from the tip of the olecranon to the proximal tendon insertion was greater than the previously reported distance obtained via gross measurement.
Gross measurement of the triceps tendon insertion overestimates and inaccurately represents the true insertional footprint. Gross measurement has been shown to demonstrate consistent disparity compared with histologic measurement. Histologic investigation provides a more accurate description.
The finding that the distance from the articular tip of the olecranon to the proximal tendon insertion is greater than previously reported may have clinical implications. A triceps split approach may allow more visualization and exposure of the posterior joint and, therefore, lessen the need for triceps detachment or olecranon osteotomy.
The Van Gorder approach for total elbow arthroplasty
2022, Journal of Shoulder and Elbow Surgery
Surgical management of the triceps during exposure for total elbow arthroplasty (TEA) is critical to a successful outcome. Previously described techniques include elevating the triceps insertion from one side or leaving the triceps insertion attached and dislocating the joint. Another approach to the elbow, first described in 1933 by Willis Campbell, MD, and subsequently modified by George Van Gorder, MD, involves turning down the triceps tendon without disrupting the triceps insertion. This approach offers complete visualization of the joint and provides excellent exposure for TEA. Only the original report of the technique and a small series of patients using this technique for TEA exist in the literature. The goal of this study was to evaluate outcomes of the Van Gorder approach in a large series of patients undergoing TEA.
All patients who underwent TEA from 2008 to 2016 were retrospectively reviewed. Only patients who underwent primary TEA performed through the Van Gorder approach with at least 6 months' follow-up were included for analysis. Patients with prior elbow surgery were excluded. Demographic data, indication for surgery, postoperative range of motion, triceps function, and need for additional surgery were recorded. Prospectively collected visual analog scale (VAS) and Global Health Quality of Life scores were also analyzed.
A total of 53 patients met inclusion criteria. The mean age was 62 years, 81% were female, and the average follow-up was 30.2 months. The most common surgical indications included inflammatory arthritis (47%), osteoarthritis (24%), and fracture (19%). Postoperatively, average elbow arc of motion was an 8°-137°. There was 1 patient (1.89%) who developed failure of their triceps extension mechanism. A total of 10 patients (19%) underwent additional elbow surgery most commonly for superficial wound complications. Preoperative VAS scores decreased significantly, starting at 3 months postoperatively (6.76 to 3.37, P < .001), and remained constant at the 12- and 24-month postoperative visits.
This is the largest study evaluating the Van Gorder surgical approach to the elbow for primary TEA with an average follow-up of 32 months. Overall rates of triceps failure and reoperation are consistent with other approaches for TEA.

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: Institutional Review Board approval: Department of Surgery, Departmental Research Committee, University of Cape Town, project number 2013/107.

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ElbowTotal elbow arthroplasty: outcomes after triceps-detaching and triceps-sparing approaches

Background

Methods

Results

Conclusion

Section snippets

Materials and methods

Results

Discussion

Conclusion

Disclaimer

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Injury

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Bilaterotricipital approach

Acta Orthop Scand

Triceps insufficiency following total elbow arthroplasty

J Bone Joint Surg Am

Elbow
Total elbow arthroplasty: outcomes after triceps-detaching and triceps-sparing approaches