Elbow Arthrodesis

Mark A. Mighell

Robert U. Hartzler

Thomas J. Kovack

BACKGROUND

Elbow arthrodesis (EA) is rarely performed in orthopaedic surgery and indicated only as a salvage procedure.
Historically, EA was performed for tuberculous septic elbow arthritis, with about 50% successful rate of primary fusion.⁸,¹⁹
With modern techniques, especially compression plating, primary fusion rates have improved somewhat from 50% to 86%,⁹,¹⁰,¹⁶ with final fusion rates including reoperation ranging from 83% to 100%.⁶,⁹,¹⁶
Reoperation for nonunion, infection, wound healing complications, and hardware prominence is common (average 1.4 to 1.6 reoperations per patient).⁹,¹⁶
EA results in greater functional disability than arthrodesis of the ankle, hip, or knee joints.
Loss of motion in the elbow is disabling and can only be partially compensated by trunk, shoulder, forearm, and wrist motion.⁴,¹²

PATIENT HISTORY AND PHYSICAL FINDINGS

Skin and soft tissue defects are evaluated.
The quality and quantity of bone available for fusion are assessed.
The surgeon should anticipate the need for bone graft or soft tissue coverage preoperatively.
If soft tissue coverage is necessary, a plastic surgery consultation is recommended.
Shoulder, forearm, wrist, and spinal column motion is evaluated.
Neurologic and motor deficits are documented.
Blood flow to the hand is determined.

IMAGING AND OTHER DIAGNOSTIC STUDIES

Standard orthogonal 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.
- Average time to fusion is usually around 6 months.³,¹⁰
- Reoperation to achieve fusion is common.⁹,¹⁶
EA should be considered a salvage procedure when no other satisfactory surgical option exists. The patient should be counseled regarding the high rate of complications.

Contraindications

Massive bone loss preventing successful arthrodesis
Massive soft tissue loss not amenable to flap reconstruction
Compromised function of the ipsilateral hand, wrist, shoulder, or spinal column

Preoperative Planning

The intended fusion position is of paramount importance, as no optimal position for arthrodesis exists.
- No fusion position will allow all activities to be performed.⁴,¹¹,¹²,¹⁸
- Historically, a fusion position of 90 degrees has been used,¹⁵ although fusion angles from 45 to 110 degrees have been recommended.¹²
The position of fusion should be dictated by the needs of the patient.
- Factors for choosing the best position include gender, occupation, hand dominance, functional requirements, associated joint involvement, and unilateral versus bilateral arthrodesis.
- If possible, preoperatively, the elbow is immobilized in various angles to determine the patient’s preferred fusion angle.
Suggested fusion angles for patient and surgeon consideration:
- Male, dominant arm: 90 degrees²,¹¹
- Females seem to prefer the cosmetic appearance of lower fusion angles (45 to 70 degrees).
- Angles greater than 90 to 100 degrees (ie, 110 degrees) allow for better hand-to-mouth function and facial hygiene.⁴,⁹,¹⁸ Conversely, cosmesis may be poor at a higher fusion angles.
  
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