General Considerations: Elbow and Wrist

Kristy L. Weber

The elbow and wrist are uncommon areas for metastatic bone disease and primary bone or soft tissue sarcomas. Large series of limb salvage procedures in these areas are not available. For primary bone and soft tissue sarcomas, multidisciplinary treatment with surgical resection, radiation and/or chemotherapy is used to maximize local control. For metastatic disease, the goal is to maintain function of the upper extremity for activities of daily living, and each case is individualized as to the surgical and nonsurgical options. The following chapters review the use of allografts and metal prostheses around the elbow for oncologic and non-oncologic scenarios. Osteoarticular (OA) allografts for distal radius tumors are also reviewed, and options for treatment of metastatic disease around the elbow and wrist are outlined.

INDICATIONS

Primary bone/soft tissue sarcomas that involve the elbow or wrist are indicated for wide resection (Figure 34-1).
Reconstruction of the elbow can be performed with an OA allograft, alloprosthetic composite, or a megaprosthesis (Figure 34-2).
Reconstruction of the wrist can be performed with an OA allograft to preserve motion or an allograft arthrodesis to avoid the complications at the joint surface.
Metastatic disease about the elbow or wrist (with or without a pathologic fracture) is indicated for internal fixation and methylmethacrylate if enough bone remains to achieve a stable reconstruction.
Modular elbow replacement can be used for solitary metastatic disease around the elbow or if there is massive bone loss that requires a prosthetic reconstruction.

CONTRAINDICATIONS

Patients with primary bone/soft tissue sarcomas and involvement of the neurovascular bundle about the elbow or wrist are not indicated for limb salvage.
Patients with growth of a primary sarcoma about the elbow or wrist on chemotherapy or radiation are not indicated for limb salvage.
Patients with a nonfunctional hand or lack of motor function to flex the elbow are not indicated for elbow reconstruction.
Patients with metastatic bone disease and a limited lifespan who can be treated with nonoperative modalities such as radiation and/or immobilization are not indicated for surgery.
Patients with an active infection of the elbow or wrist are contraindicated for a prosthetic or allograft reconstruction.