INDICATIONS

We reserve resection arthroplasty for septic total elbow replacements, especially when reimplantation cannot be done.

TECHNIQUE

To remove a well-fixed implant, a trapezoid-shaped cortical window is removed from the posterior aspect of the distal humerus (Fig. 67-1). Care is taken to preserve the epicondyles (Fig. 67-2). The olecranon is positioned between the two columns. We use a No. 3 PDS suture to help stabilize this relationship.

FIGURE 67-1 Resecting a well-fixed total elbow arthroplasty can be accomplished by removing a trapezoid-shaped segment of the posterior humerus. This allows access to the medullary canal. The length of this should allow at least two diameters of reinsertion of an implant should that be necessary. Possibly more importantly, this should carefully be done in order to maintain the medial and lateral condyles.

FIGURE 67-2 Patient with resected arthroplasty after an infected total elbow (A and B). Notice that the medial and lateral columns have been maintained (A). This patient has a Mayo Elbow Performance Score of 80 and a functional elbow.

AFTERCARE

A cast is applied for 6 weeks. Protected motion is begun using a Mayo Elbow Brace (Donjoy International, Vista, CA) and continued for an additional 6 to 8 weeks (Fig. 67-3).

FIGURE 67-3 The Mayo Elbow Brace is helpful in immobilizing and stabilizing the extremity in the early phases and then allowing flexion and extension in the later phases.

RESULTS

We have just completed an assessment of 59 resected elbows after failed total elbow arthroplasty (TEA) for sepsis at a mean time of 12 years after surgery. Although the study is still under way, preliminary analysis demonstrates a clear distinction between those with “contained” articulation (Fig. 67-4) having medial and lateral condyles doing markedly better than those with more extensive resection preventing any opportunity for a fulcrum effect (Fig. 67-5). Custom orthotic braces are occasionally prescribed, but infrequently worn on a regular basis (Fig. 67-6).

FIGURE 67-4 Two years after resection arthroplasty, notice the maintenance of the medial and lateral columns.

FIGURE 67-5 A, In some instances, a complete resection of the joint may be indicated. This is usually in the case of sepsis. However, the result is dysfunctional instability. B, The use of the extremity is markedly compromised due to a windmill type of global instability.

FIGURE 67-6 A custom-fit prosthesis is sometimes employed after resection arthroplasty. Compliance is low, however.

SEGMENTAL BONE LOSS

The unstable or “flail” elbow with segmental bone loss, that is, complete loss of articulation and ligament attachments, is difficult to manage. Treatment with a primary replacement is discussed in Chapters 59 and 66. This problem can be a sequel of trauma, infection, failed elbow arthroplasty, or tumor resection. Bone may be lost at the original injury following a severe open fracture, or it may be removed subsequent to infection, particularly if the fragment is avascular. In treating recalcitrant union of supracondylar fractures, surgeons have in the past (and disastrously) succumbed to the temptation to remove the condylar fragment of the humerus and treat the problem by inserting an endoprosthesis.

If the problem is limited to just the articular region of the humerus, a hemireplacement may be effective (Fig. 67-7). If, however, all stability and distal contour of the humerus is lost, today, a linked replacement is performed for such patients (see Chapter 59).

FIGURE 67-7 The instances in which there is loss of articular surface and bone but maintenance of collateral origins allows a hemireplacement of the joint and is an attractive option that has recently emerged.

On the other hand, in the situation of a flail elbow, particularly in a young patient, arthrodesis may be considered (see Chapter 70). However, failure of fusion, even under optimal conditions, has been high in some series^2,14,16 and successful arthrodesis is unlikely in patients with large bone stock deficiencies. Reconstruction procedures, such as those involving reattachment of muscles more proximally on the humerus or interposing a tongue of triceps muscle into the gap, are unlikely to be successful. Muscle transfer procedures can improve flexion in cases of flail elbow associated with paralysis, but in these cases, the problem is of a different nature. A successful outcome will occur only if a stable fulcrum is provided and muscles are restored to their normal functioning length.