Anil K. Dutta
The indications for elbow arthrodesis (EA) are exceedingly rare. There is little accommodation for the loss of elbow motion from adjacent joints, and extremity function is severely compromised after fusion. Indications currently are limited to unsalvageable cases of sepsis, neoplasms, severe bone loss after multiple arthroplasties, or high-energy trauma with no potential for joint reconstruction (1,2,3,4,5,6,7,8,9 and 10) (Table 32-1).
Multiple techniques for fusion have been attempted (Table 32-2). Early techniques utilized limited fixation with isolated screws for compression (1,3,6,11). These were often employed for the treatment of destructive arthritis in the setting of tuberculosis. Compression plate osteosynthesis (CPO) quickly evolved into the most commonly reported technique over time (4,5,8,9). Fusion rates significantly improved with CPO, and it remains the preferred method of fixation when possible. Alternative techniques have included external fixation, external fixation with limited internal fixation, and external fixation with compression plates (2,12,13).
The optimal position for fusion has been evaluated in a number of studies, and 90 degrees of flexion remains the preferred position in most series, although some advocate flexion up to 110 (14). Ninety degrees of flexion provides the optimal position for strength of the hand and wrist for younger patients seeking a return to manual labor (15). Alternate positions may be considered in patients who require extension for specific work functions such as computer typing, and bilateral fusions should be done with slight flexion in one arm and extension in the other. The uncertainty over fusion position reflects the underlying conundrum of performing EA, as there may ultimately be no optimal position (16).
Results of EA are limited to a relatively small number of case series as the procedure is uncommon. Original reports focused on management of tuberculosis involvement of the elbow joint and showed mixed results with a frequent failure of the arthrodesis (1,6,11). Arafiles showed improved results in the setting of tuberculosis with a modified technique by incorporating a triangle wedge of proximal ulna into a matching defect in the olecranon fossa (1). Koch and Lipscomb (3) described the Mayo Clinic experience with 17 patients, but fusion rates remained around 50%. Rashkoff et al. (5,8) described plate fusion in the setting of open trauma with an emphasis on combat injuries. Importantly, all wounds were left open and healed successfully by secondary intention, with five out of six patients noting good to excellent results. They also described placing the plate anterior in two patients as an option when pathology or infection was predominantly posterior. Another description of EA in the setting of war injuries was performed by Bilic et al. (2) who performed EA with use of an external fixator and a compression screw. Eight of nine patients showed good results and return to satisfaction with regard to limb function and pain. Recent descriptions of fusion have continued to show better satisfaction rates and fusion rates with the increasing emphasis on CPO. Koller et al. (4) described fusion successfully in 14 of 14 patients using a combination of CPO and external fixation. Reichel et al. (9) described results in 12 patients in the setting of high-energy civilian trauma and achieved confirmed fusion in 11.
Strategies to deal with bone deficiency are required in special circumstances when large bone defects are present (Table 32-3