Advancement in total elbow arthroplasty care

General introduction 

The elbow joint is a multi-axle joint that enables the human arm to be functional in daily life. A well-functioning elbow is of high importance in everyday activities. Because of changing needs in daily life, such as the use of mobile phones and computers, the need for greater range of motion of the elbow has arisen in the last decades. Impairment of elbow function causes disability, ultimately leading to the diminishment of quality of life. 

As the elbow is a complex joint, which consists of three bones that ingeniously fit together, its construction and location in the upper extremity make it prone to traumatic damage with forthcoming malalignment or degeneration. On the long term, osteoarthritis is seen in up to 80% of patients with an elbow fracture. Repetitive injuries and progressive degeneration may lead to such impairment, that normal functioning in daily life becomes compromised. Moreover, several pathological processes of degeneration may impair elbow function. Inflammatory diseases such as rheumatoid arthritis are better treated nowadays with biologicals with the forthcoming benefits of less joint destruction. 

The simplest solution to elbow joint malfunction is to adapt activities to a lower level of functioning, which would imply the acceptance of a worse functioning joint. However, the patient usually would not accept such adjustments, thus requests treatment. A difference should be made between foremost loss of range of motion, instability and pain, as these three problems need a different management. Range of motion can be addressed by an (arthroscopic) debridement with good results. Instability is usually a result of injuries to the medial and/or lateral collateral ligaments, potentially worsened by loss of congruency of the joint. Pain however, is more difficult to solve, especially when the aforementioned problems have been addressed. When activities as eating, drinking and personal care become impossible, an attempt to reconstruct the joint is needed. 

Such a reconstruction is possible with an arthroplasty; when both the humerus and ulna are replaced, the prosthesis is called a total elbow arthroplasty. Unfortunately, the implant survival of elbow arthroplasties is less satisfying than hip and knee arthroplasties. Over the years, the indications for a total elbow arthroplasty are changing from rheumatoid arthritis, to foremost posttraumatic osteoarthritis and comminuted fractures. 

To understand the contemporary arthroplasty models, it is important to understand the historical background. During the twentieth century, component design and fixation methods have changed. Concept-changing interventions, such as non-anatomical replacement of the joint to regain function, have led to better clinical results and total elbow prosthesis being a regularly accepted intervention. Through trial and error, different fixation mechanisms have been tested and dismissed, such as screw fixation of the implant. Linked and non-linked designs, as well as restrained and non-restrained designs have diverse indications for use, as learned from the past. 

Nowadays, a variety of implants and surgical approaches are available when opting for total elbow arthroplasty. The literature is inconclusive with regard to the choice of a ‘best’ prosthesis and a ‘best’ surgical approach. The choice is therefore often dependent on the surgeons’ skills and preferences, and last but not least, patient characteristics.