CHAPTER SYNOPSIS:
Elbow arthrodesis is a rarely indicated and difficult procedure. When all other options have failed, elbow arthrodesis creates a painless, stable joint. There is no angle of fusion that is ideal for all activities, but most authors recommend 90 degrees of flexion. Prearthrodesis functional bracing in varying degrees of flexion is highly recommended. Many operations are described in the literature. Procedure selection depends on surgeon experience, the indication, and patient factors such as the presence of infection and soft tissue and bone loss. Outcomes of elbow arthrodesis are variable, and complications and additional procedures are common.
IMPORTANT POINTS:
Elbow arthrodesis is a salvage operation that has significant functional limitations.
The primary indication is recalcitrant infection or, when no other options are possible secondary to infection, bone or soft tissue compromise.
The position of arthrodesis is controversial and should be simulated prior to proceeding with surgery.
The patient should fully understand the high risk of complication associated with this procedure.
CLINICAL/SURGICAL PEARLS:
Acceptable fusion angle may be different for individual patients depending on their activity level and expectations from this procedure. The fusion angle should be simulated with bracing or casting prior to proceeding with elbow arthrodesis.
Compromised soft tissues and infections should be addressed prior to elbow arthrodesis.
Use aggressive debridement of the remaining articular surface and sclerotic bone until healthy cancellous bone is exposed.
Rigid compression across the arthrodesis site and liberal bone grafting are essential for successful fusion.
CLINICAL/SURGICAL PEARLS:
Acceptable fusion angle may be different for individual patients depending on their activity level and expectations from this procedure. The fusion angle should be simulated with bracing or casting prior to proceeding with elbow arthrodesis.
Compromised soft tissues and infections should be addressed prior to elbow arthrodesis.
Use aggressive debridement of the remaining articular surface and sclerotic bone until healthy cancellous bone is exposed.
Rigid compression across the arthrodesis site and liberal bone grafting are essential for successful fusion.
INTRODUCTION
Improved prevention and treatment of tuberculosis has drastically decreased the incidence of tuberculosis of the elbow, which historically was the primary indication for elbow arthrodesis. Primary and revision total elbow arthroplasties have yet to reach the same level of efficacy as hip, knee, and shoulder arthroplasty, but their steadily improving clinical outcomes continue to further shrink the indications for elbow arthrodesis. Although rarely used as the initial treatment option, elbow arthrodesis remains an effective operation to salvage the upper extremity in select cases of severely compromised elbow function. This is a rarely performed and technically challenging procedure. However, when patients are carefully selected and appropriate techniques are used, most patients in whom arthrodesis is achieved are satisfied and have no desire to return to their prearthrodesis state. The goal is to create a stable, painfree elbow that can be used to place the hand in space with the assistance of adjacent joints.
INDICATIONS/CONTRAINDICATIONS
Recalcitrant osteomyelitis of the elbow with resultant joint destruction remains the primary indication for elbow arthrodesis. Other indications include repeatedly failed total elbow arthroplasty, arthritic diseases unsuitable for arthroplasty, and severely comminuted intraarticular fractures with large bone and soft tissue defects. It is also a viable option in young patients with debilitating arthritis whose occupations require a strong and stable joint, such as manual laborers. A total elbow arthroplasty would be expected to fail when subjected to repetitive heavy loads in this patient population.
Normally, the shoulder and elbow are the main joints responsible for performing the critical function of positioning the hand in space. After elbow arthrodesis, patients compensate by making adjustments at the shoulder, scapulothoracic, and spinal joints. It was initially assumed that the shoulder provided the greatest compensatory movement, but O’Neill and colleagues showed that the thoracic and lumbar spine actually provide the greatest assistance after elbow fusion. Participants in this study increased truncal torsion to move the arm laterally and increased spinal flexion and extension to move the elbow in and out of space. The shoulder and scapulothoracic joints provided negligible assistance when compared to spinal adjustments. Therefore, concomitant dysfunction in these joints, especially the spine, that is severe enough to limit the requisite compensatory movements is a contraindication to elbow arthrodesis. The resultant limited ability to position the hand in space would preclude most useful functions of the extremity.
POSITION OF ARTHRODESIS
Fusion of the shoulder, hip, knee, or ankle does not produce major functional disabilities because the adjacent joints are able to compensate for the loss of motion. The elbow is unique in that adjacent joints cannot completely compensate for the loss of elbow motion, and there is no angle of fusion that is ideal for all activities. Despite a paucity of objective data, most authors recommend 90 degrees of flexion for unilateral fusion. If bilateral elbow arthrodesis is necessary, many recommend fusion of >90 degrees (range, 110 to 120 degrees) in the dominant arm for feeding and facial hygiene and fusion of <90 degrees (range, 45 to 60 degrees) in the nondominant arm for lower extremity and personal hygiene activities. In a study of simulated elbow arthrodesis by functional bracing, Tang and colleagues found that the 110-degree fusion angle produced significantly higher mean functional scores for activities of daily living and nonsignificantly improved scores for personal care and hygiene tasks when compared to 90 degrees. However, this study did not include pertinent occupational tasks such as typing and driving, and the participants were young and healthy and may not be representative of the elbow arthrodesis patient population. The position of arthrodesis must consider the patient’s age; occupation; hand dominance; compromise of function in the spine, shoulder, wrist, and contralateral upper extremity; and the patient’s preference. The choice of fusion angle must be individualized to meet each patient’s specific needs. It is highly recommended to simulate fusion via functional bracing at different angles prior to the procedure. It is also prudent to refer patients to physical and occupational therapists for simulation and evaluation of the myriad of situations that will be encountered in activities of daily living. The angle of fusion is critically important and must be chosen carefully.
SURGICAL TECHNIQUES
The difficulty of achieving stable elbow fusion is reflected in the many different surgical techniques that have been described. Many early techniques relied on various osteotomies and autografts with postoperative cast immobilization to achieve fusion. Steindler presented a successful case of elbow fusion using a tibial autograft wedged into the olecranon and affixed to the humerus with screws. Brittain presented a case of fusion using two crossed humeroulnar tibial autografts without screw fixation. Koch and colleagues presented 17 cases of elbow arthrodesis using various techniques with an overall fusion rate of 47%. It is important to note that all five cases that used the Brittain procedure as the initial or revision procedure resulted in fusion. Staples described a successful arthrodesis using an iliac graft affixed to the humerus and osteotomized ulna using two screws after a failed Steindler procedure ( Fig. 24-1 ).
Contemporary techniques of elbow arthrodesis use internal fixation with rigid compression plates and screws, compression screws alone, external fixators, or various combinations of the three. Debridement of the distal humerus and proximal ulna down to bleeding, healthy bone, compression across the arthrodesis, and synovectomy are common to all contemporary techniques. Radial head resection, bone grafting, and ulnar nerve transposition are used variably. No study has conclusively shown a benefit to radial head resection with elbow arthrodesis, but many authors recommend it. Bone grafting is recommended to fill any voids because nonunion is a common complication of elbow arthrodesis. The ulnar nerve should always be identified and protected because it is vulnerable during the majority of these cases as the posterior approach to the elbow is used. Depending on the amount of bone resected and the position of hardware placement, ulnar nerve transposition may be required.
COMPRESSION SCREW
Irvine and Gregg described short-term successful elbow arthrodesis results in three patients with posttraumatic arthritis in whom total elbow arthroplasty was considered inappropriate. With the patient in the lateral decubitus position, a 15-cm longitudinal incision is made, centered over the olecranon. The elbow joint is entered via an inverted V -shaped triceps tendon flap, the radial head is resected, and the articular surfaces of the humerus and ulna are debrided down to bleeding, healthy, congruent bone ( Fig. 24-2A ). Cancellous iliac crest bone graft is packed into the sigmoid notch, and the elbow is secured in the appropriate position using two crossed malleolar screws inserted from the olecranon into the supracondylar ridge. The thin cortical bone of the olecranon fossa and posteromedial and posterolateral aspects of the olecranon are removed. Additional cancellous bone is packed into the olecranon fossa and corticocancellous strips are laid over the whole decorticated area ( Fig. 24-2B ). After closure, a posterior splint is placed and then later replaced by a long arm cast once sutures are removed. Radiographic fusion was documented at 16 weeks in all three cases, at which time the casts were removed ( Fig. 24-3 ).
