Elbow Arthrodesis
BACKGROUND
Elbow arthrodesis (EA) is rarely performed in orthopaedic surgery and indicated only as a salvage procedure.
Historically, EA was performed for tuberculous septic elbow arthritis, with about 50% successful rate of primary fusion.8,19
With modern techniques, especially compression plating, primary fusion rates have improved somewhat from 50% to 86%,9,10,16 with final fusion rates including reoperation ranging from 83% to 100%.6,9,16
Reoperation for nonunion, infection, wound healing complications, and hardware prominence is common (average 1.4 to 1.6 reoperations per patient).9,16
EA results in greater functional disability than arthrodesis of the ankle, hip, or knee joints.
Loss of motion in the elbow is disabling and can only be partially compensated by trunk, shoulder, forearm, and wrist motion.4,12
PATIENT HISTORY AND PHYSICAL FINDINGS
Skin and soft tissue defects are evaluated.
The quality and quantity of bone available for fusion are assessed.
The surgeon should anticipate the need for bone graft or soft tissue coverage preoperatively. If soft tissue coverage is necessary, a plastic surgery consultation is recommended.
Shoulder, forearm, wrist, and spinal column motion is evaluated. Neurologic and motor deficits are documented.
Blood flow to the hand is determined.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Standard orthogonal radiographs of the elbow are obtained.
Computed tomography (CT) scans of the elbow are obtained for more detailed bony anatomy. If infection is suspected:
Blood work is obtained for complete blood count, sedimentation rate, and C-reactive protein. The joint is aspirated or an indium scan is performed.
SURGICAL MANAGEMENT
The elbow is one of the most difficult joints to fuse because of the long lever arm and strong bending forces across the fusion site.
Average time to fusion is usually around 6 months.3,10
Reoperation to achieve fusion is common.9,16
EA should be considered a salvage procedure when no other satisfactory surgical option exists. The patient should be counseled regarding the high rate of complications.
Contraindications
Massive bone loss preventing successful arthrodesis Massive soft tissue loss not amenable to flap reconstruction
Compromised function of the ipsilateral hand, wrist, shoulder, or spinal column
Indications
Septic arthritis, postseptic arthrosis, or chronic osteomyelitis
Complex traumatic or war injuries with unreconstructable bone and soft tissue defects
Elbow degenerative joint disease in patients who are too young or active for total elbow arthroplasty (eg, laborer)
Painful, severe instability
Failed internal fixation for nonunions or pseudarthrosis Failed elbow arthroplasty (rare)2
Preoperative Planning
The intended fusion position is of paramount importance, as no optimal position for arthrodesis exists.
No fusion position will allow all activities to be performed.4,11,12,18
Historically, a fusion position of 90 degrees has been used,15 although fusion angles from 45 to 110 degrees have been recommended.12
The position of fusion should be dictated by the needs of the patient.
Factors for choosing the best position include gender, occupation, hand dominance, functional requirements, associated joint involvement, and unilateral versus bilateral arthrodesis.
If possible, preoperatively, the elbow is immobilized in various angles to determine the patient's preferred fusion angle.
Suggested fusion angles for patient and surgeon consideration:
Male, dominant arm: 90 degrees2,11
Females seem to prefer the cosmetic appearance of lower fusion angles (45 to 70 degrees).
Angles greater than 90 to 100 degrees (ie, 110 degrees) allow for better hand-to-mouth function and facial hygiene.4,9,18 Conversely, cosmesis may be poor at a higher fusion angles.
Fifty to 70 degrees is better for extrapersonal needs.18
Bilateral EA: dominant arm at 110 degrees, nondominant arm at 65 degrees9,15
The need for vascularized bone or flap coverage may significantly affect preoperative planning:
Healing by secondary intention has been described with acceptable results, even in the setting of exposed hardware.15
Consider staging flap coverage and the use of external fixation.3
Vascularized fibular autograft for bone loss17 and pedicled rib-latissimus dorsi flap13 for combined bone and soft tissue defects have been described.
P.4068
Assess bone loss and the need for bone graft or alternative fusion methods:
For cases with no or minimal bone loss, consider demineralized bone matrix, cancellous allograft, or autograft.
For large bone defects, autograft cancellous bone is preferable.
Radiohumeral arthrodesis in the setting of inadequate ulnar bone has been described.14
Compression with lag screws plus plating or external fixation has improved the rate of primary fusion compared with historical techniques and should be part of the surgical tactic.
The addition of a 3.5-mm locked plate placed medially as a strut to enhance the rigidity of the construct has been described.5
Most authors recommend routine excision of the radial head, especially in the setting of infection.1,3,5,10 Alternatively, if the radiocapitellar and proximal radioulnar joints are relatively preserved, it is acceptable to maintain the radial head if it does not interfere with the arthrodesis.9,16
Some loss of forearm rotation should be anticipated.9,10,15
Special Instruments
Large fragment locking set (4.5-mm locked narrow plate)
A 3.5-mm locked plate may be substituted in smaller patients. External fixator of surgeon's preference, if applicable
Sterile goniometer Plate press
High-speed burr Power drill Osteotomes Oscillating saw Kirschner wire set
Patient Positioning
A tourniquet is placed as high on the arm as possible. A sterile tourniquet is required to increase the zone of sterility.
The patient is placed in the lateral decubitus position with the operative arm resting on a padded arm rest. Adequate intraoperative fluoroscopic imaging should be ensured.
Anesthesia
Antibiotics are given 30 minutes before the incision.
General anesthesia is used for intraoperative pain control and allows paralysis if necessary. A supraclavicular block can be used for intraoperative and postoperative pain management.
TECHNIQUES
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Surgical Approach
Mark existing surgical scars and use prior incisions if possible. The preferred incision is a direct posterior approach to the elbow.
If flap coverage is present, a plastic surgeon may be required for exposure to preserve the vascular pedicle to the flap.
With flaps with vascular pedicles, the location of the vessel can be located intraoperatively with a Doppler.
Create full-thickness flaps right down to the bone. Limit subcutaneous dissection.
Split the triceps tendon longitudinally.
Carry the triceps split distally in the interval between the flexor carpi ulnaris (FCU) and the anconeus.
Identify the ulnar nerve and make sure it remains protected.
Identify neurovascular structures in known areas before following structures through areas of heavy scar tissue.
Arthrodesis
Osteotomy and Reduction
Expose the dorsal surface of the distal humerus and proximal ulna. Use osteotomes to “fish scale” the exposed bone.
Open the medullary canal of the humerus and ulna.
Perform a step cut osteotomy of the proximal ulna and distal humerus to increase the surface area for fusion (TECH FIG 1A).
Contour the bone so that it can be reduced at the appropriate angle chosen for arthrodesis.
It is often necessary to excise the radial head to allow for adequate reduction of the humerus and ulna.
Reduce the distal humerus to the proximal ulna.
Confirm the fusion angle with a sterile goniometer (TECH FIG 1B).
Provisionally, hold the reduction at the desired angle with 1.6-mm Kirschner wires.
Screw and Plate Fixation
Drill from distal to proximal for lag screw insertion (TECH FIG 2A).
Use two or three lag screws (4.5 mm) whenever possible.
Apply the 4.5-mm locking plate posteriorly, prebent at the chosen angle of arthrodesis (TECH FIG 2B).
A long plate should be selected with a minimum of 10 to 14 holes. A plate press is easier to use than bending irons.
The plate functions as a neutralization device.
All compression is achieved with the lag technique employed for screw placement.
The plate is pulled down to the bone and secured with cortical screws before adding locked screws.
Use at least one locked screw proximal and distal to the fusion site to increase the torsional strength of the construct (TECH FIG 2C).
Completion
Check the position and fixation of the construct intraoperatively with fluoroscopy. The final construct should demonstrate compression across the fusion site.
The plate should conform securely to the bone at the desired angle of fusion (TECH FIG 3A).
Irrigate and close the wound.
We recommend the use of one or two deep flat drains.
Final radiographs should be taken intraoperatively (TECH FIG 3B,C).
P.4069
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TECH FIG 1 • A,B. Step cut in distal humerus (B) and proximal ulna (C). This is a multiplanar cut and should accommodate for the elbow position in both the coronal and sagittal planes. The step cut provides a larger surface area for primary bone healing. Intraoperative use of a goniometer to confirm the fusion angle before definitive fixation (A).
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TECH FIG 2 • A. Placement of lag screw. B. Provisional fixation is obtained with Kirschner wires and the fusion position is measured with a goniometer (A). Screws are placed from distal (C) to proximal (B) in a crossed configuration. Two or three lag screws are placed before plate application. Plate placement after the fusion angle has been confirmed. (continued)
P.4070
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TECH FIG 2 • (continued) C. A guide for locking the screw through the plate and across the step cut osteotomy. Compression must be achieved before locking screws are placed. A, distal humerus; B, proximal
ulna.
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TECH FIG 3 • A. Completed EA using step cut osteotomy and 3.5-mm locking plate and lag screw technique. A, distal humerus; B, proximal ulna. B,C. Anteroposterior (AP) and lateral postoperative radiographs of left elbow fusion using step cut osteotomy and locked plating technique.
PEARLS AND PITFALLS
Step cut bone to increase the surface area for healing.
Place lag screws in both vertical and horizontal planes to increase compression. Maintain full-thickness dorsal tissue, including the periosteum.
Use lag technique to compress the bone ends.
Never identify neurovascular structures in areas of extensive surgical scarring. Work from known to unknown surgical fields.
Open the medullary canal to facilitate blood flow.
Select a plate of sufficient length to span the fusion site. Longer plates are desirable.
Place locking screws only after reduction and compression of the bone ends and the plate is compressed to bone with conventional screws.
Keep patients in a cast until fusion occurs, typically a minimum of 4-6 months.
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POSTOPERATIVE CARE
Drains are removed before hospital discharge.
Intravenous antibiotics are continued for 48 hours or longer, depending on intraoperative cultures. Sutures or staples are removed at 2 weeks.
The arm is placed in a long-arm cast at the 2-week visit.
Cast or splint immobilization is continued until there is radiographic evidence of union, typically 4 to 6 months at minimum.3,7,10
COMPLICATIONS
Postoperative fracture after bony union has been achieved is not uncommon8,9 but may be successfully treated with immobilization in the majority of cases.
REFERENCES
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Beckenbaugh R. Arthrodesis. In: Morrey BF, ed. The Elbow and Its Disorders, ed 3. Philadelphia: WB Saunders, 2000:731-737.
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Bilic R, Kolundzic R, Bicanic G, et al. Elbow arthrodesis after war injuries. Mil Med 2005;170(2):164-166.
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de Groot JH, Angulo SM, Meskers CG, et al. Reduced elbow mobility affects the flexion or extension domain in activities of daily living. Clin Biomech 2011;26(7):713-717.
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Galley IJ, Bain GI, Stanley JC, et al. Arthrodesis of the elbow with two locking compression plates. Tech Shoulder Elbow Surg 2007;8(3): 141-145. doi:110.1097/BTE.1090b1013e31812dfb31885.
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Presnal BP, Chillag KJ. Radiohumeral arthrodesis for salvage of failed total elbow arthroplasty. J Arthroplasty 1995;10(5):699-701.
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Ring D, Jupiter JB, Toh S. Transarticular bony defects after trauma and sepsis: arthrodesis using vascularized fibular transfer. Plast Reconstr Surg 1999;104(2):426-434.
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Tang C, Roidis N, Itamura J, et al. The effect of simulated elbow arthrodesis on the ability to perform activities of daily living. J Hand Surg Am 2001;26(6):1146-1150.
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Van Gordner GW, Chen CM. The central-graft operation for fusion of tuberculous knees, ankles, and elbows. J Bone Joint Surg Am 1959;41-A:1029-1046.