Mark A. Mighell and Thomas J. Kovack
BACKGROUND
Elbow arthrodesis is a rarely performed orthopaedic procedure.
It is mainly performed for severe joint destruction due to.
Posttraumatic arthrosis
Instability
Infection
Historically, it is performed for a tuberculous infection of the elbow.1
Early fusion rates are about 50%.1
With modern techniques, fusion rates approach 50% to 100%.3,9
Arthrodesis of the elbow results in greater functional disability than arthrodesis of the ankle, hip, or knee joints.
Satisfactory shoulder function is a prerequisite, even though it does not compensate for loss of motion in the elbow.2
Compensatory motion is seen more in the spinal column and wrist.
A functional hand is also desirable when performing arthrodesis of the elbow.
No optimal position for arthrodesis exists.
The position of fusion is dictated by the needs of the patient.
PATIENT HISTORY AND PHYSICAL FINDINGS
Skin and soft tissue defects are evaluated.
The surgeon should evaluate the need for bone graft or soft tissue coverage before arthrodesis.
If soft tissue coverage is necessary, a plastic surgery consultation is recommended.
Shoulder, wrist, and spinal column motion is evaluated.
Neurologic and motor deficits are documented.
Blood flow to the hand is determined.
The quality and quantity of bone available for fusion are assessed.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Standard radiographs of the elbow are obtained.
Computed tomography (CT) scans of the elbow are obtained for more detailed bony anatomy.
If infection is suspected.
Blood work is obtained for complete blood count, sedimentation rate, and C-reactive protein.
The joint is aspirated or an indium scan is performed.
SURGICAL MANAGEMENT
The elbow is one of the most difficult joints to fuse because of the long lever arm and strong bending forces across the fusion site.
Arthrodesis should be considered a salvage procedure when no other satisfactory surgical option exists.
Indications
Septic and tuberculous arthritis
Sequela of septic arthritis
Complex war injuries (with large bone and soft tissue defects)
Young healthy laborers with posttraumatic arthritis who are too young for total elbow arthroplasty
Posttraumatic arthrosis or severe instability
Pseudarthrosis
Severely comminuted intra-articular fractures of the distal humerus with joint destruction
Chronic osteomyelitis
Failed elbow arthroplasty
Failed internal fixation for nonunions
Contraindications
Massive bone loss preventing successful arthrodesis
Massive soft tissue loss not amenable to flap reconstruction
Compromised function of the ipsilateral shoulder, wrist, and spinal column
Preoperative Planning
The best elbow position is controversial, although the literature suggests between 45 and 110 degrees.
Historically, 90 degrees is accepted as the best position.
Factors for choosing the best position include.
Gender
Occupation
Hand dominance
Functional requirements
Associated joint involvement
Unilateral versus bilateral arthrodesis
Patient preference
One to 3 weeks before surgery, the elbow to be fused is braced or casted in various angles.
Generally acceptable angles include.
Male: dominant arm at 90 degrees
Females seem to prefer lower angles of 40 to 70 degrees.
Ninety to 110 degrees is better for personal hygiene.
Forty to 70 degrees is better for extrapersonal needs and activities.
Bilateral elbow arthrodesis: dominant arm at 110 degrees, nondominant arm at 65 degrees
Soft tissue coverage is evaluated.
Flap coverage or skin grafts are performed before arthrodesis.
If soft tissue coverage is required, the joint is stabilized with an external fixator.
The surgeon should consider bulk graft with demineralized bone matrix and cancellous allograft or autograft.
For large bone defects, autograft cancellous bone is preferable.
Antibiotics are given 30 minutes before the incision.
General anesthesia is used.
An axillary or interscalene block can be used.
Special Instruments
Large fragment locking set (4.5-mm locked narrow plate)
A 3.5-mm locked plate may be substituted in smaller patients.
Sterile goniometer
Plate press
High-speed burr
Power drill
Osteotomes
Oscillating saw
Kirschner wire set
Patient Positioning
A tourniquet is placed as high on the arm as possible. A sterile tourniquet is required to increase the zone of sterility.
The patient is placed in the lateral decubitus position with the operative arm resting on a padded arm rest.
TECHNIQUES
SURGICAL APPROACH
Mark existing surgical scars and use prior incisions.
Use a direct posterior approach for the elbow.
An anterior approach may be needed if the tissue is compromised posteriorly.
If flap coverage is present, a plastic surgeon may be required for exposure.
Flaps with vascular pedicles can be located with Doppler.
Create full-thickness flaps right down to the bone.
Split the triceps tendon longitudinally.
Carry the triceps split distally in the interval between the flexor carpi ulnaris (FCU) and the anconeus.
Identify the ulnar nerve and make sure it remains protected.
Identify neurovascular structures in known areas before following structures through areas of heavy scar tissue.
ARTHRODESIS
Osteotomy and Fracture Reduction
Expose the dorsal surface of the distal humerus and proximal ulna.
Use osteotomes to “fish-scale” the exposed bone.
Open the medullary canal of the humerus and ulna.
Perform a step-cut osteotomy of the proximal ulna and distal humerus to increase the surface area for fusion (TECH FIG 1A).
Contour the bone so that it can be reduced at the appropriate angle chosen for arthrodesis.
It is often necessary to excise the radial head to allow for adequate reduction of the humerus and ulna.
Reduce the distal humerus to the proximal ulna.
Confirm the fusion angle with a sterile goniometer
(TECH FIG 1B).
Provisionally hold the reduction at the desired angle with 1.6-mm Kirschner wires.
Screw and Plate Fixation
Drill from distal to proximal for lag screw insertion (TECH FIG 2A).
Use two or three lag screws whenever possible.
Apply the 4.5-mm locking plate posteriorly, prebent at the chosen angle of arthrodesis (TECH FIG 2B).
A long plate should be selected with a minimum of 10 to 14 holes.
A plate press is easier to use than bending irons.
The plate functions as a neutralization device.
All compression is achieved with the lag technique employed for screw placement.
The plate is pulled down to the bone and secured with cortical screws before adding locked screws.
Use at least one locked screw proximal and distal to the fusion site to increase the torsional strength of the construct (TECH FIG 2C).
Completion
Check the position and fixation of the construct intraoperatively with fluoroscopy.
The final construct should compress well at the fracture site.
The plate should conform securely to the bone at the desired angle of fusion (TECH FIG 3A).
Irrigate and close the wound.
Place one or two deep flat drains.
Final radiographs should be taken intraoperatively (TECH FIG 3B,C).
TECH FIG 1 • A. Step-cut in distal humerus and proximal ulna. This is a multiplanar cut and should accommodate for the elbow position in both the coronal and sagittal planes. The step-cut provides a larger surface area for primary bone healing. B. Intraoperative use of a goniometer to confirm the fusion angle before definitive fixation.
TECH FIG 2 • A. Placement of lag screw. Screws are placed from distal to proximal in a crossed configuration. Two or three lag screws are placed before plate application. Provisional fixation is obtained with Kirschner wires and the fusion position is measured with a goniometer. B. Plate placement after the fusion angle has been confirmed. C. A guide for locking the screw through the plate and across the stepcut osteotomy. Compression must be achieved before locking screws are placed. A, distal humerus; B, proximal ulna.
TECH FIG 3 • A. Completed elbow arthrodesis using step-cut osteotomy and 3.5-mm locking plate and lag screw technique. A, distal humerus; B, proximal ulna. B,C. AP and lateral postoperative radiographs of left elbow fusion using step-cut osteotomy and locked plating technique.
POSTOPERATIVE CARE
Drains are removed before hospital discharge.
Intravenous antibiotics are continued for 48 hours or longer, depending on intraoperative cultures.
Sutures or staples are removed at 2 weeks.
The arm is placed in a long-arm cast at the 2-week visit.
The patient is placed in serial casts for at least 4 months.
Cast application is continued until there is radiographic evidence of union.
REFERENCES
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