Internal fixation a legitimate alternative to total elbow arthroplasty in nonunion cases
One physician says his experience leads him to believe total elbow arthroplasty may not always be necessary.
Jesse B. Jupiter
Total elbow arthroplasty – while a viable option in many cases – does not have to be the go-to procedure in cases of nonunions and malunions in the elbow, according to one physician’s experience.
“In the era of arthroplasty, there is a tendency to say these are so problematic that we need to put in a total arthroplasty,” said Jesse B. Jupiter, MD, at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons.
Jupiter also pointed out that treatment of nonunions and malunions in the elbow can often be more about recognizing the specific anatomy in play and how to correct issues without resorting to a surgery as extensive as total elbow arthroplasty (TEA).
“When I put this together with an adequate follow-up, I had 90 cases,” he said. “I base this on my own experience, but I hope that I can also present to you the problems that I personally experiences so you can avoid them. Most I have attempted to treat with internal fixation.”
Different non- and malunions
Jupiter’s breakdown of the various types of nonunions outlined the depth of the understanding one has to have in correcting non- and malunion issues.
Images: Jupiter J
“You can have a supracondylar nonunion, but it may be a synovial nonunion and/or it may be associated with bone loss,” he said. “There may be ones that just involve the intercondylar area, and often they may be combined: intra- and supracondylar. The worst ones are the very-low transcondylar – those where you can look at the X-ray and not see much bone.”
Bring in capsulectomy
Though many of the different types of nonunion can be treated with internal fixation, Jupiter said he learned “the hard way” that such treatment should be combined with capsulectomy.
“Otherwise, you have a good, solid union, but very little motion,” he said. “Capsulectomy as well will decrease the stress on your internal fixation, because the elbow will now be moving through its joint rather than at the original nonunion site.”
In working with supracondylar nonunions, Jupiter said that sometimes a false joint may be found with sclerosis at the distal aspect.
“It may seem like there is a little bit of bone there, and we are becoming more and more used to anatomically shaped plates,” he said. “I do not think these are so good when you have distorted anatomy,” he said.
“My own preference has been to use malleable plates that can be contoured to meet the anatomic needs, rather than the pre-shaped plates,” he added. “And if you do a capsulectomy, many of these patients will regain a good function of motion.”
Jupiter stressed the importance of acknowledging the ulnar nerve.
“One of the things I learned the hard way was that patients who have these and who have limited motion and previous surgery and complain of pain … it may be coming from their ulnar nerve,” he said. “Secondly, if they have had a previous surgery, whatever surgery you plan to do – be it arthroplasty or internal fixation – the ulnar nerve may be out of its normal anatomy and may be in fibrosis.”
Jupiter labeled this part of the procedure “tedious,” but noted that if the ulnar nerve is not released in a stiff elbow that gains motion, the patient may develop traction neuritis of the ulnar nerve – which could potentially be “very symptomatic.”
He added, “This is a important part in any elbow reconstructive surgery.”
Also important is proper care with the proximal elevation of the osteotomy, Jupiter said, as the cartilage may be adherent and pull from the trochlea when lifted.
Maximize the motion
“Once you have a stable fixation, the next step is to make certain that one can maximize the amount of motion,” Jupiter said. “It really helps if you can get as much motion as possible. [Multiple] plates are often needed because of distorted anatomy and the need to get better distal fixation.”
Understanding the fracture is critical when trying to give an elbow motion again, Jupiter said. He noted that what often happens is the capsule contacts and distal fragment are often flexed, resulting in what appears to be a “modest” piece of distal bone.
“Once you have done a capsular release, you will find there is considerably more bone,” he said. “The point is, once you are down at this level – once you have had a synovial joint – you have had erosion of bone. There will be anatomic distortion, and there will be sclerosis at both ends that one needs to open up.”
“If one has that, what I like to do is take the shaft and create a ‘v,’ then take the distal fragment and create a recess,” he added. “It gives you better bone contact and vascular bone contact.”
Jupiter concluded by noting that sometimes a seemingly hopeless joint can still be brought back.
“It [might look] awful. There may be a lot of fibrosis around the joint … and there is a temptation to say ‘this is not salvageable,’” he said. “The caveat is if the trochlea width is maintained, cartilage will live regardless. Once they become mobilized, it is amazing that there really are not long-term problems with arthrosis.” – by Robert Press
- Jupiter JB. Treatment of nonunions and malunions about the elbow. Presentation IV in the Complex Elbow Injuries: Trauma and Reconstruction – How to Manage and Avoid Complications symposium. Presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons. March 9-13, 2010. New Orleans.
- Jesse B. Jupiter, MD, can be reached at firstname.lastname@example.org.