INTRODUCTION

The ankylosed elbow occurs spontaneously or after formal intent. In either instance, the functional outcome is usually not well tolerated. The reason for this is, first, there is no “optimum” position for elbow fusion. The joint is designed to position the hand in space and to one’s self. Second, the other joints compensate poorly for loss of elbow motion. Analysis of compensatory motion after an elbow arthrodesis has documented a compromised ability to complete activities, despite a significantly increased dependence on spine and wrist motion (Fig. 58-1).¹⁰ Furthermore, the shoulder plays only a modest role in compensation. For these reasons, there is continued value and interest in managing the stiff elbow by prosthetic replacement. The goal is to attain a functional arc of motion.⁷

FIGURE 58-1 The shoulder functions as a ball and joint, whereas the elbow is a hinge allowing flexion and extension. The conal or circumferential motion of the shoulder does not compensate for the to-and-fro motion of the elbow.

INDICATIONS AND PATIENT SELECTION

The primary goal of total elbow arthroplasty is to restore motion to improvement function. We prefer a patient older than 60 years of age if the pathology follows trauma.⁸ However, pathologic and functional considerations may prompt replacement at an earlier age, especially in those with inflammatory conditions. Of note is that the extent of comorbidities that tends to exist in these patients further complicates the execution of the procedure.

Radioulnar, radiohumeral, or a combination of these synostoses, with complete loss of forearm rotation, may occur in more than 33% of patients (Fig. 58-2).¹¹ The incidence of additional joint involvement in the ipsilateral and contralateral extremities was 77% and 46%, respectively, in our experience. In fact, in our experience, an isolated elbow fusion occurred in less than 10% of patients.

FIGURE 58-2 Loss of forearm rotation is common in patients with ankylosed elbows following spontaneous fusion from inflammatory conditions.

Post-traumatic neuropathies are also common and may occur in as many as 40% of patients. As a matter of fact, two patients in our published series had previous Volkmann’s ischemic contracture. These complications mitigate the age factor when considering this procedure.

CONTRAINDICATIONS

Subacute sepsis is an absolute contraindication for conversion of a fused to a total elbow replacement. Chronic sepsis must be carefully assessed with a sedimentation rate and C-reactive protein studies. A staged procedure is performed if there is any question about active infection.

Poor skin coverage is a relative contraindication that can be addressed by soft tissue procedures before the joint replacement (Fig. 58-3). Unwillingness to comply with the 5-kg single event, 1-kg repetitive weight restriction is a reason not to perform total elbow replacement. This implies those involved with heavy use of the extremity such as construction workers should not be offered this operation.

FIGURE 58-3 Because of poor soft tissue in many patients, a preoperative soft tissue reconstruction is essential in order to avoid wound problems after the surgery.

PREOPERATIVE ASSESSMENT

The patient’s functional demands are carefully documented. The precise daily limitations and the impact to one’s daily existence is precisely determined. Presence and ability of the triceps to contract is noted. The examination also specifically evaluates the neurovascular status of the extremity. The quality of the skin is noted. The function of the contralateral elbow and the ipsilateral shoulder, hand, and wrist is documented. The flexibility of the cervical spine is assessed.

RADIOGRAPHIC EVALUATION

Usually, plane films are adequate. Size and quality of the bone, and angular deformity is noted. We pay close attention to the presence of the olecranon and determine by physical examination if the triceps is attached. The size of the medullary canal and presence and relevance of fixation devices is considered (Fig. 58-4).

FIGURE 58-4 A, Gross angular deformity is common. The presence of internal fixation devices increases the likelihood of infection. B, Ectopic bone is the most common postoperative problem that prevents maintenance of functional motion.

EXPECTATIONS

Before surgery, the goals, limitations, and risks are very carefully explained to the patient. Expected outcomes are described based on our experience with approximately 20 cases.^5,11

The high degree of osseous and soft tissue involvement adds a high level of complexity to the procedure. The operative time exceeds 2 hours and, in many instances, requires serial application and release of the tourniquet.