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La cúpula radial en la protesi

total del codo
Pr Christian Dumontier MD, PhD
Presentation is available at www.diuchirurgiemain.org

Complications of TEA

43 % at 5 years with 18 % re-operations

Aseptic loosening (17,2 % on X-rays & 6,4 %
clinically) and Instability (range 7 to 19 %) are
among the most frequent

They partly depend on the design of implants and
the surgical technique !

Complications of TEA

Would the use of a radial head
prosthesis have changed the
evolution of these prostheses in
those patients ?

What are the rationale for radial head preservation /
replacement / resection ?

Anatomical and experimental
works have shown that the
MCL is the major stabilizer in
the frontal plane

MCL and coronoid process in
the sagittal plane

The stabilization of the normal elbow joint relies on structures that
belong to the « ulna » anatomy

However

If the MCL is absent /
insufficient

Then the native radial
head becomes a
MAJOR stabilizer

Because there is a
synergy between bones
and ligaments

A radial head prosthesis is also a stabilizer

If MCL is released, then radial
head replacement almost restabilize the elbow

Jensen SL, Olsen BS, Tyrdal S, Sojbjerg JO, Sneppen O. Elbow joint laxity after experimental radial head excision and lateral
collateral ligament rupture: efficacy of prosthetic replacement and ligament repair. J Shoulder Elbow Surg 2005; 14(1): 78-84.

A radial head prosthesis is also a stabilizer

In the sagittal plane, the radial head
(with LCL) stabilizes the elbow (for
example in terrible triads)

And the radial head also sustains loads from the forearm

About 60% of the load goes through the radio-capitelar joint

40

60

In Total elbow replacement

In most pathologies were a TEA is
needed, the MCL is deficient

Then preservation/replacement of
the radial head would seem logical

First Prostheses were linked, uniaxial and fully constrained

They did not include radial
head replacement

They have been abandoned
in the 70’s

However I was not aware of a Colombian prosthesis

In which a radial
head prosthesis was
included
Bichernal was a
precursor ?

Evolution of TEA was then in two directions

Not linked prostheses trying to resurface the elbow joint

Linked prostheses with a floppy hinge
Linked

Unlinked

Coonrad-Morrey Capitellocondylar
Norway

Kudo

GSBIII

Norway

Pritchard

Sorbie

Discovery

Souter

Linkable
Acclaim
Latitude

Not linked TEA may be unstable

Intra-prothetic dislocation
became a major problem

With increased frequency
with time (up to 15%) as the
MCL elongates

Not linked TEA may be unstable

Variations of frequency vary
according to prosthetic design

Not linked TEA & radial head
Evaluation of a convertible elbow prosthesis

In most TEA, radial
head replacement was
not considered

Figure 1 Right elbow: subluxation 9 years after Kudo IV. Left
elbow: valgus instability 7 years after Kudo V.

Worldwide both linked and unlinked prostheses are
used. A concern of the unlinked prostheses is instability of
the prosthesis. Literature21,23,25 shows a 2.3-4.9% dislocation of unlinked elbow prostheses shortly after surgery.
Furthermore, a ‘tardy’ valgus instability has been described
in a rather large number of cases 3-5 years postoperative.3
Progressive insufficiency of the medial collateral ligament
(MCL), in combination with resection of the radial head
and progressive polyethylene, wear results in gradual

Figure
thesis.
compon
can be p
panel,
compon

recomm
current
elbow
to the
The
varus a
of the
radial
and (3
compo

Not linked TEA & radial head

In its early design, the
capitellocondylar (Ewald) included a
radial head prosthesis

However, due to increased lucencies on
the humerus, it was withdrawn from
the market

In a late publication (1991), Ewald
reported good results with 4 years FU
(8 cases) but his conclusions on
whether or not replace the radial head
were unclear

Not linked TEA & radial head

The Mayo team has shown
the importance of radial head
replacement for the SorbieQuestor prostheses (2002)

The GUEPAR group has also
shown that a radial head adds
some stability (2001)

Not linked TEA & radial head

Mayo team also reviewed 46
Pritchard III TEA with 10 years FU
with the use of a radial head in 89%
of cases

83% of complications with 50%
survival

Most radial head were either badly
inserted and/or wrongly designed
with asymmetric polyethylene wear

They however concluded that a
well designed and inserted radial
head would be useful

Linked TEA and radial head replacement

In those prostheses, no radial
head replacement was
included in the design

Mayo team in 709 TEA were
able to maintain the radial
head in 70% of cases (and in
56% of RA patients)

They recommend to maintain
the radial head if possible, not
to replace it

Lingenfelter EJ, Adams RA, Morrey B Management of the radial head and linked total elbow arthroplasty. J
Shoulder Elbow Surg 2011; 20, 625-30.

What about the new prostheses ?

Discovery is linked

Acclaim, Latitude are linkable

Only in the Latitude, a radial
head replacement is part of the
technique

Is the « Latitude » concept validated ?
Evaluation of a convertible elbow prosthesis

Yes, radial head
replacement increased
stability
of both the
tion of athe
convertible
elbow prosthesis
unlinked and linked
device

On cadavers at day 0
Figure 1 Right elbow: subluxation 9 years after Kudo IV. Left
elbow: valgus instability 7 years after Kudo V.

Figure 2 Left panel, The disassem
thesis. It consists of 4 components: h
component, bi-polar radial head, and th
can be placed on the ulnar component to
panel, The linked Latitude trial prosth
component held in place before the cap

recommendations can be given to th
Worldwide both linked and unlinked prostheses are
currently available
biomechanical
p
Figure 2 ofN.
Left
panel,ofThe
disassembled
Latitude
used.ML,
A De
concern
of Hendriks
the unlinked
is instability
Wagener
VoS MJ,
JCM,prostheses
Eygendaal D,
Verdonschot
Stability
the unlinked
Latitude
totaltrial
elbow
system, whether
not to lin
thesis.
It consists2013;
of
428:components:
humeralorcomponent,
shows
a 2.3-4.9%
dislocathe
prosthesis.
Literature21,23,25
elbow
prosthesis:
A biomechanical
in vitro
analysis.
Clinical Biomechanics
502-8.
to the radial head.
component,
tion of unlinked elbow prostheses shortly after
surgery. bi-polar radial head, and the ulnar cap. The ulna

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1 It is probably worth reproducing the

elbow anatomy in TEA but using a
radial head prosthesis raises major
concerns (which are almost identical
with preservation of the native radial
head)

Some important questions

Is radial head replacement a major or a minor
biomechanical improvement ?

How do the loads on the radio-capitular joint act on the
TEA ?

Do radio-capitular loads alter the normal biomechanics of
TEA and increase stress on the bone-prosthesis (ou bonecement) interface ?

Which radial head replacement ?

1- Radial head replacement a major improvement ?

To date, no one has any
convincing answer

Theoretically, preservation of
radial head or its replacement
would be useful

IF and ONLY IF normal
anatomy and biomechanics are
reproduced +++

TEA « cannot » reproduce normal biomechanics of the elbow

Anterior offset: 9.5 ± 2.3 mm (H) and 7.5
± 1.2 mm (F) p<0.01. No relationship with DCT

DCT (center of trochlea and center of
capitulum) : 21.9 ± 1.9 mm (H) and 18.6
± 2.0 mm (F) (reflects the size of the
humeral implant)

Axis of the humerus is distant from
CDT : X= 0.090 ± 0.025 (H) & X = 0.170 ±
.020 (F)

The axis of rotation is not fixed (a cone
with medial submit from extension to
flexion)

Brownhill JR, JSES, 2006, 15(4) - Goto A, JSES 2004, 13(4)

2- Radial head preservation / replacement modifies the loads on
TEA

If normal anatomy and
biomechanics cannot be
reproduced ?

It will add some constraints like
for overstuffed RHR

2- Radial head preservation / replacement modifies the loads on
TEA

A not well designed and well fitted
RHR will rise loads

It the loads are not balanced with the
ulno-humeral constraints

Asymmetrical loads will increase
the risk of loosening +++

Radial head loosening at 1 year FU

3- which radial head prosthesis ?
Avanta
Mopyc
KPS

Evolve
Corifix-Amis

Swanson

GUEPAR

CRF

3- which radial head prosthesis ?

The anatomy of the native radial head is
also very variable

Either its position over the neck and
diaphysis

None of the radial head prosthesis designed
does reproduce this complex anatomy

Conclusion: Due to
the high frequency of
complications of TEA
R

L

R

TABLE 54-2 -- Results of Approximately 800 Semiconstrained Joint Replacements from 18 Studies
No.
Follow- Extension- Pronation- Pain
Total
% with up
Flexion
Supination Relief Complications Revised Satisfa
Study
Implant
Patients Arthritis (years) (degrees) (degrees) (%) (%)
Loose(%) Result
Inglis and Triaxial
44
64
3.5


89
36
2

Pellicci,
1980[21]
Pritchard, Pritchard II
92
60
2.5


98
15
2
85
1981[38]
Bayley,
Stanmore
30
90
3.5
107 arc
107 arc
67
67

70
1981[1]
Rosenberg Pritchard I and 14
100
2.6


100 53

94
and
II
Turner,
1982[41]
Bell et al, GSB III
45
82
2.6
29-137
65-60
96
25
5
87
1986[4]
Gschwend, GSB III
71
72
4
29-140
69-64
93
27

91
1988
Leber and Triaxial
11
100
4 (est) 30-132
75-75
91
36

91
Melone,
1988
Madsen et Pritchard II
25
100
3
28-130
65-62
100 8
1
92
al, 1989[32]
Morrey
Coonrad47
100
>5
30-135
60-65
90
32
4
90
and
Morrey
Adams,
1992[34]
Kraay et Triaxial
113
76
5



2

al, 1994[26]
Gschwend GSB III
118
82
4.3



11
3
90 *
et al,
1996[18]
Risung,
Norway
118
100
4.3


95
9
2
95
1997[40]
Gill and
Coonrad69
100
12.5
28-131
68-62
95
18
3
93
Morrey,
Morrey
1998[15]
Lo et al,
Coonrad14
3
35-125
0
0
0
100
2003[30]
Morrey
/Linked Total Elbow Arthroplasty in Patients with Rheumatoid Arthritis/INTRODUCTION
09/06/
Lee et al, Coonrad8
3.5


100

100
2005[28]
Morrey
al,
2006[22]
Jensen
et GSB III
16
5
90
3
75
Aldridge et Coonrad/Morrey
41
20


13
78
al, 2006[1]
http://www.expertconsultbook.com/expertconsult/b/book.do?method…0-B978-1-4160-2902-1..50059-0&type=bookPage&contentStyle=print
Page
Cesar et GSB III
44
6




2
84
al, 2007[8]
Totals
818
83
6
30-130
67-63
93
20
20
89

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d
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2 To date, there are

so many problems
to solve with TEA
that radial head
replacement may
not be a priority

GRACIAS POR SU GENTIL INVITACIÓN!

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