Orthopedics

Tips & Techniques 

Elbow Arthrodesis: A Novel Technique and Review of the Literature

Thomas J. Kovack, DO; Paul B. Jacob, DO; Mark A. Mighell, MD

Abstract

The elbow is a complex joint that is the mechanical link in the upper extremity between the hand and the shoulder. Loss of elbow function can severely affect activities of daily living. Arthrodesis of the elbow results in greater functional disability than arthrodesis of the ankle, hip, or knee joints. Arthrodesis is mainly performed for severe joint destruction most commonly due to posttraumatic arthrosis, instability, or infection. The authors describe a new technique of elbow arthrodesis using a step-cut osteotomy that has not been previously reported. They believe that this can increase the surface area for healing with the outcome of a higher fusion rate. It is most important, however, to achieve good compression with lag screws across the fusion site after the desired angled has been achieved. Elbow arthrodesis is not a common orthopedic procedure, but the authors believe that their novel technique provides a reproducible and reliable way to achieve a high fusion rate and desired fusion angle. [Orthopedics. 2014; 37(5):313–319.]

The authors are from Orthopedic Specialists of Central Ohio (TJK), Hilliard, Ohio; the Doctors Hospital of Columbus (PBJ), Columbus, Ohio; and the Florida Orthopedic Institute (MAM), Tampa, Florida.

Dr Jacob has no relevant financial relationships to disclose. Dr Kovack receives consultant payments from Arthrex, DJO Surgical, Upex, and DePuy Mitek. Dr Mighell receives consultant payments from, as well as lectures and serves on the speaker’s bureau for, DJO Surgical.

Correspondence should be addressed to: Paul B. Jacob, DO, Doctors Hospital of Columbus, 5100 W Broad St, Columbus, OH 43228 ( pjacob2664@hotmail.com).

Received: April 02, 2013
Accepted: September 05, 2013

Abstract

The elbow is a complex joint that is the mechanical link in the upper extremity between the hand and the shoulder. Loss of elbow function can severely affect activities of daily living. Arthrodesis of the elbow results in greater functional disability than arthrodesis of the ankle, hip, or knee joints. Arthrodesis is mainly performed for severe joint destruction most commonly due to posttraumatic arthrosis, instability, or infection. The authors describe a new technique of elbow arthrodesis using a step-cut osteotomy that has not been previously reported. They believe that this can increase the surface area for healing with the outcome of a higher fusion rate. It is most important, however, to achieve good compression with lag screws across the fusion site after the desired angled has been achieved. Elbow arthrodesis is not a common orthopedic procedure, but the authors believe that their novel technique provides a reproducible and reliable way to achieve a high fusion rate and desired fusion angle. [Orthopedics. 2014; 37(5):313–319.]

The authors are from Orthopedic Specialists of Central Ohio (TJK), Hilliard, Ohio; the Doctors Hospital of Columbus (PBJ), Columbus, Ohio; and the Florida Orthopedic Institute (MAM), Tampa, Florida.

Dr Jacob has no relevant financial relationships to disclose. Dr Kovack receives consultant payments from Arthrex, DJO Surgical, Upex, and DePuy Mitek. Dr Mighell receives consultant payments from, as well as lectures and serves on the speaker’s bureau for, DJO Surgical.

Correspondence should be addressed to: Paul B. Jacob, DO, Doctors Hospital of Columbus, 5100 W Broad St, Columbus, OH 43228 ( pjacob2664@hotmail.com).

Received: April 02, 2013
Accepted: September 05, 2013

The elbow, a complex joint, serves as the mechanical link in the upper extremity between the hand and the shoulder. The elbow functions as a caliper to position the hand in space for both fine movements and powerful grasping. Loss of elbow function can severely affect activities of daily living.1 The functional disability that results from elbow arthrodesis is the reason why fusion is rarely performed. Arthrodesis of the elbow results in greater functional disability than arthrodesis of the ankle, hip, or knee joints.

Historically, arthrodesis was performed when treating patients with tuberculous infection of the elbow. The reported fusion rate was approximately 50% for patients who underwent arthrodesis for the treatment of tuberculosis. Arafiles2 described 11 patients, 6 of whom were followed for 2 years, with a tuberculous elbow. The technique involved an extensive debridement, total synovectomy with radial head excision, and insertion of a triangle-shaped olecranon into a similarly shaped hole in the distal humerus. Fixation was achieved with a single screw through both the distal humerus and the olecranon.

Fusion rates range from 50% to 100% with current techniques. Satisfactory shoulder function is a prerequisite, although it does not compensate for loss of motion in the elbow. Compensatory motion is seen more in the spinal column and wrist. A functional hand is also desirable when performing arthrodesis of the elbow. The optimal position for arthrodesis is debatable. Arthrodesis is mainly performed for severe joint destruction most commonly due to post-traumatic arthrosis, instability, or infection. Table 1 lists the indications and contraindications for arthrodesis.1–8

Indications and Contraindications for Arthrodesis

Table 1:

Indications and Contraindications for Arthrodesis

Fusion Angle

There is no ideal angle or position to fuse the elbow. The patient will experience significant functional limitations regardless of selected position. The literature suggests that the fusion angle lies somewhere between 45° and 110°.9 Historically, 90° has been accepted as the best position. Factors to consider when choosing the position include sex, occupation, hand dominance, functional ability of the opposite upper extremity, and functional requirements. In addition, ipsilateral shoulder and wrist pathology and patient preference should be considered. To better determine the ideal position for fusion, it is advisable to brace or cast the patient’s elbow at various angles. The patient can then offer feedback regarding the most desirable angle for arthrodesis. Men tend to prefer angles for fusion between 70° and 90°, whereas women seem to prefer lower angles between 40° and 70°. For both sexes, 90° to 110° seems to be better for personal hygiene, whereas 40° to 70° is better for extrapersonal needs and activities. In the case of bilateral elbow arthrodesis, it is generally recommended that the dominant arm be fused at 110° and the nondominant arm at 65°.9–12

Physical Examination

A physical examination is performed to determine the procedure that will best serve the patient. The external appearance and the quality of the soft tissues must be evaluated. Determining whether a flap or graft is needed or even possible is the first step in identifying the appropriate procedure. A plastic surgery consultation may be helpful in determining the type of closure that would be most beneficial to the patient. It is also important to evaluate the function of the shoulder and the wrist of the same extremity. Poorly functioning ipsilateral joints may decrease the likelihood of an acceptable outcome for the patient. The neurologic status of the upper extremity must be evaluated and documented. It is not uncommon for there to be brachial plexus or other peripheral nerve injury that needs to be taken into consideration. It is always pertinent to evaluate the vascular status of a mangled upper extremity. Blood flow distal to the elbow can be an important consideration when determining surgical procedure. Finally, the quality and quantity of bone available for fusion must be assessed.

Diagnostic Tests

Laboratory as well as diagnostic tests should be performed prior to determining the appropriate procedure. Standard radiographs should be obtained to assist with pre-operative planning. Computed tomography will be helpful in determining the bony anatomy and planning for allograft and autograft needs intraoperatively. Preoperative blood work should include the standard infectious workup (complete blood count, erythrocyte sedimentation rate, C-reactive protein). An indium scan should be obtained if infection is suspected. An intraoperative soft tissue biopsy in conjunction with Gram stain and cultures could also prove helpful in determining if infection is present.

Preoperative Planning

Preoperative planning should follow an algorithm similar to the surgeon’s pre-operative evaluation. Soft tissue coverage needs must be evaluated and must be part of planning. If needed, a plastic surgery consultation should be obtained prior to the procedure. Flap or skin grafting procedures must be performed prior to the arthrodesis. If a flap or graft is required, consideration should be given to stabilizing the joint with an external fixator prior to the fusion. The need for bulk graft with demineralized bone matrix and cancellous allograft or autograft must be considered. For large bone defects, autograft cancellous bone is preferable.

Techniques

The elbow is one of the most difficult joints to fuse, primarily due to its long lever arm and strong bending forces across the fusion site. Several previous techniques13–15 and current techniques2,3,5,6,10–25 to achieve elbow fusion are listed in Table 2 and Table 3, respectively.

Previous Techniques for Elbow Fusion

Table 2:

Previous Techniques for Elbow Fusion

Current Techniques for Elbow Fusion

Table 3:

Current Techniques for Elbow Fusion

The Authors’ Preferred Technique

The authors prefer to perform a step-cut osteotomy (Figure 1). The step-cut osteotomy is performed on the proximal ulna and distal humerus to increase the surface area for fusion. Bones preventing reduction of the osteotomy should be contoured at the desired fusion angle. The appropriate fusion angle can be verified using a sterile goniometer intraoperatively. It is often necessary to excise the radial head to allow for adequate reduction of the humerus and ulna. Remaining capitellum is cleared of articular cartilage and bleeding bone is exposed. The cut ends of the distal humerus are coupled to the proximal ulna. A K-wire will allow for a provisional reduction at the desired angle. Provisional reduction is obtained with 1.6-mm K-wires. The lag technique is used for compression across the osteotomy (Figure 2). A 3.5- or 4.5-mm narrow dynamic compression plate is used to neutralize forces across the joint. A long plate with a minimum of 10 to 14 holes should be selected. The plate is bent and contoured to the dorsal surface of the distal humerus and ulna. Initial screws should be placed bicortical to pull the plate to the bone. The construct is only locked in case of poor bone quality after the osteotomy site is reduced and compressed. Locked screws used at the end of plates have been implemented with caution due to risk of causing a stress riser. Details regarding special instruments, anesthesia, and patient and equipment position used by the authors are presented in Table 4.

Illustration depicting a sagittal plane step-cut in the distal humerus and proximal ulna. This is a multiplanar cut and should accommodate for the elbow position in both the coronal and the sagittal planes. The step-cut provides a larger surface area for primary bone healing. (Reprinted with permission from Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Wolters Kluwer Health, 2011.)

Figure 1:

Illustration depicting a sagittal plane step-cut in the distal humerus and proximal ulna. This is a multiplanar cut and should accommodate for the elbow position in both the coronal and the sagittal planes. The step-cut provides a larger surface area for primary bone healing. (Reprinted with permission from Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Wolters Kluwer Health, 2011.)

Illustration of placement of the lag screws. Screws are placed from distal to proximal in a crossed configuration. Two or 3 lag screws are placed prior to plate application. Provisional fixation is obtained with K-wires and the fusion position is measured with a goniometer.

Figure 2:

Illustration of placement of the lag screws. Screws are placed from distal to proximal in a crossed configuration. Two or 3 lag screws are placed prior to plate application. Provisional fixation is obtained with K-wires and the fusion position is measured with a goniometer.

Operating Room Setup

Table 4:

Operating Room Setup

Illustrative Case

A 23-year-old woman was involved in a rollover accident and presented with an open distal humerus fracture. There was loss of the majority of the articular surface, which became infected despite multiple formal debridements. Reconstruction with a structural allograft including the trochlea was attempted. Eighteen months after reconstruction, the patient developed instability and collapse of the articular surface. The patient was placed in a lockable range of motion elbow brace to determine her preferred elbow position. She preferred the brace to be locked at 60° to 70°. Preoperative radiographs demonstrated incorporation of the allograft but instability of the ulnohumeral joint with collapse of the articular surface (Figure 3).

Anteroposterior (A) and lateral (B) radiographs before fusion of a posttraumatic elbow after multiple failed attempts to salvage, including bulk allograft.

Figure 3:

Anteroposterior (A) and lateral (B) radiographs before fusion of a posttraumatic elbow after multiple failed attempts to salvage, including bulk allograft.

Surgical Technique

Existing surgical scars are marked and prior incisions are used whenever possible. The direct posterior approach is preferred for the elbow. However, the anterior approach may need to be considered if tissue is compromised posteriorly. If flap coverage is present, a plastic surgery consultation should be considered for exposure of the flap. The ulnar nerve must be identified and protected. All neurovascular structures must be identified in known areas before dissecting structures through areas of heavy scar tissue. Next, the dorsal surface of the distal humerus and proximal ulna is exposed. Osteotomes are used to “fish-scale” the exposed bone. The medullary canal of the humerus and ulna is opened. A step-cut osteotomy is performed on the proximal ulna and distal humerus to increase the surface area for fusion. The bone is contoured so that it can be reduced at the angle chosen for arthrodesis. It is often necessary to excise the radial head to allow for adequate reduction of the humerus and ulna. The cut ends of the distal humerus are coupled to the proximal ulna. The K-wire allows for a provisional reduction at the desired angle. Drilling is performed from distal to proximal for lag screw insertion (Figure 4). Two or 3 lag screws are used whenever possible. A 4.5-mm locking plate, pre-bent at the chosen angle of arthrodesis, is applied posteriorly (Figure 5). The authors prefer a plate press over bending irons. The plate can be bent to the desired angle using a goniometer. The plate functions as a neutralization device as the compression is achieved with the lag technique employed for screw placement. The plate is pulled down to the bone and secured with cortical screws prior to adding locked screws if needed (Figure 6). Again, caution is necessary when using locking screws at the ends of the plate to avoid a stress riser. Fluoroscopy is used intraoperatively to check the position and fixation of the construct. The final construct should be well compressed at the fracture site and the plate should conform securely to the bone at the desired angle of fusion (Figure 7). Finally, the wound is irrigated and closed. Placement of 1 to 2 deep flat drains should be considered. Final radiographs should be obtained intraoperatively (Figure 8).

Intraoperative photograph of a left elbow during provisional fixation of a step-cut osteotomy with K-wires and placement of a 3.5-mm lag screw. Abbreviations: A, distal humerus; B, proximal ulna; C, step-cut osteotomy; D, 3.5-mm cortical lag screw; E, proximal reduction held with K-wires.

Figure 4:

Intraoperative photograph of a left elbow during provisional fixation of a step-cut osteotomy with K-wires and placement of a 3.5-mm lag screw. Abbreviations: A, distal humerus; B, proximal ulna; C, step-cut osteotomy; D, 3.5-mm cortical lag screw; E, proximal reduction held with K-wires.

Intraoperative photograph (A) and illustration (B) of a goniometer showing the angle of fusion after bending the plate on a press. (Reprinted with permission from Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Wolters Kluwer Health, 2011.)

Figure 5:

Intraoperative photograph (A) and illustration (B) of a goniometer showing the angle of fusion after bending the plate on a press. (Reprinted with permission from Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Wolters Kluwer Health, 2011.)

Intraoperative photograph of a guide for locking the screw through the plate and across the step-cut osteotomy. Compression must be achieved before locking screws are placed. Abbreviations: A, distal humerus; B, proximal ulna. (Reprinted with permission from Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Wolters Kluwer Health, 2011.)

Figure 6:

Intraoperative photograph of a guide for locking the screw through the plate and across the step-cut osteotomy. Compression must be achieved before locking screws are placed. Abbreviations: A, distal humerus; B, proximal ulna. (Reprinted with permission from Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Wolters Kluwer Health, 2011.)

Intraoperative photograph of a completed elbow arthrodesis using a step-cut osteotomy and 3.5-mm locking plate and lag screw technique. Abbreviations: A, distal humerus; B, proximal ulna. (Reprinted with permission from Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Wolters Kluwer Health, 2011.)

Figure 7:

Intraoperative photograph of a completed elbow arthrodesis using a step-cut osteotomy and 3.5-mm locking plate and lag screw technique. Abbreviations: A, distal humerus; B, proximal ulna. (Reprinted with permission from Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Wolters Kluwer Health, 2011.)

Postoperative anteroposterior (A) and lateral (B) radiographs of a left elbow fusion using a step-cut osteotomy and locked plating technique. (Reprinted with permission from Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Wolters Kluwer Health, 2011.)

Figure 8:

Postoperative anteroposterior (A) and lateral (B) radiographs of a left elbow fusion using a step-cut osteotomy and locked plating technique. (Reprinted with permission from Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Wolters Kluwer Health, 2011.)

Postoperative Care

The drains are removed prior to hospital discharge. Intravenous antibiotics are continued for 48 hours or longer, depending on the results of intraoperative cultures. An infectious disease consultation may be necessary depending on intraoperative culture results. At 2 weeks postoperatively, the sutures are removed and the arm is placed in a long arm cast. Serial casting should be used. Continuing casting until radiographic evidence of union should be considered. A custom functional brace can be fabricated if skin hygiene is an issue and to allow for bathing. The authors’ recommendations regarding this technique are presented in Table 5.

Authors’ Recommendations Regarding Their Technique

Table 5:

Authors’ Recommendations Regarding Their Technique

Discussion

Elbow arthrodesis was originally most commonly performed for joint destruction from tuberculosis of the elbow.2,5 Given the improvement in medical management, arthrodesis is now rarely needed for tuberculosis of the elbow.18 Indications for fusion most commonly include elbows that are severely injured with resulting bone loss, infection, articular surface destruction, painful loss of motion, elbow instability, or failed total elbow arthroplasty.3,5,10,11,18,25

Elbow arthrodesis is a reasonable option to relieve pain and maintain some, although limited, function of the extremity.3,5,10,11,18,25 It is a salvage procedure, used only when other surgical options would likely fail, and thus is not commonly performed.11,18,25 Therefore, the literature on this topic is limited and mostly involves case reports or studies with small numbers of patients. Only 3 studies have included more than 12 patients.10 Due to the paucity of cases, there is a lack of consensus on the single best way to perform an elbow arthrodesis.11,18,25 Fusion rates are reported to range from 56% to 100% using compression plating and external fixation without one superior technique.18 Fusion of the elbow is technically difficult to achieve due to the significant forces acting across the elbow joint.5,18

The technical aspect of obtaining a fusion of the elbow has changed significantly over time. In 1923, Steindler13 reported a technique that used bone graft without internal or external fixation, followed by several months of immobilization. In 1979, Müller et al17 and the AO recommended a compression technique of the joint surfaces using a partially threaded cancellous screw from the olecranon to the humerus with additional compression provided by an external fixator. In 1986, Rashkoff and Burkhalter11 described successful fusion with anterior or posterior compression plates when used with iliac crest bone graft. Within the past 10 years, most of the literature has continued to recommend anterior or posterior plating with or without external fixation as well as other novel techniques. Posterior plating is most commonly reported, although anterior ulnohumeral compression plating has also been described.3,5,10,25 Other reported techniques include external fixation combined with internal fixation using a cancellous screw with washer and iliac crest bone graft,3 unilateral external fixation with daily advancement of flexion until 90° is obtained,5 single or double fibular grafts to bridge bony defects,18 and a latissimus dorsi flap with an attached vascularized rib graft for bony deficit.8

Ozer et al23 reported that the 3 main challenges to elbow arthrodesis were the choice of ideal fusion construct, whether to use bone graft, and the ideal fusion angle for a functional arm. An optimal fusion angle of 90° for a unilateral fusion has generally been recommended.26 Tang et al,12 in a study consisting of 24 healthy volunteers, examined the function of the elbow by measuring activities of daily living and personal care and hygiene tasks in incremental ranges of motion from 30° to 130°, using a functional brace. They found that functional scores regarding difficulty with activities of daily living and personal care and hygiene tasks were best with flexion of the elbow at 110°, followed by 130° and then 90°. On further analysis, these results showed a statistical difference favoring 110° over 90° regarding activities of daily living and personal care and hygiene tasks plus activities of daily living, but no significant difference with personal care and hygiene tasks only. Ideal elbow position remains debatable and needs to be addressed on an individual basis, with personal activities, occupation, age, and dominant vs nondominant handedness dictating the optimal angle for each patient. Extra-personal and lower extremity activities favor a position of less flexion, whereas interpersonal care and hygiene activities favor increased flexion.12

Conclusion

The authors have described a previously unreported technique for elbow arthrodesis using a step-cut osteotomy. They believe that the inherent stability achieved with a step-cut and the increased surface area for healing will yield a higher fusion rate. When performing this technique, compression must be achieved with lag screws across the fusion site after the desired angled has been achieved. The forces across the joint are then neutralized with a plate. In cases of osteoporosis, a locked plate can be used. When there is no concern about the bone quality, a standard compression plate is selected. The authors prefer either a large fragment 4.5-mm narrow plate or, in the case of a smaller patient, a small fragment 3.5-mm plate.

Elbow arthrodesis is not a common orthopedic procedure. In cases where it is necessary, the authors believe that their technique using a step-cut osteotomy offers a reliable way to achieve a high fusion rate at the desired fusion angle.

References

  1. Fornalski F, Gupta R, Lee TQ. Anatomy and biomechanics of the elbow joint. Tech Hand Up Extrem Surg. 2003; 7(4):168–178. doi:10.1097/00130911-200312000-00008 [CrossRef]
  2. Arafiles RP. A new technique of fusion for tuberculous arthritis of the elbow. J Bone Joint Surg Am. 1981; 63(9):1396–1400.
  3. Bilic R, Kolundzic R, Bicanic G, Korzinek K. Elbow arthrodesis after war injuries. Mil Med. 2005; 170(2):164–166.
  4. Gallo RA, Payatakes A, Sotereanos DG. Surgical options for the arthritic elbow. J Hand Surg Am. 2008; 33(5):746–759. doi:10.1016/j.jhsa.2007.12.022 [CrossRef].
  5. Koller H, Kolb K, Assuncao A, Kolb W, Holz U. The fate of elbow arthrodesis: indications, techniques, and outcome in fourteen patients. J Shoulder Elbow Surg. 2008; 17(2):293–306. doi:10.1016/j.jse.2007.06.008 [CrossRef]
  6. Lerner A, Stein H, Calif E. Unilateral hinged external fixation frame for elbow compression arthrodesis: the stepwise attainment of a stable 90-degree flexion position: a case report. J Orthop Trauma. 2005; 19(1):52–55. doi:10.1097/00005131-200501000-00010 [CrossRef]
  7. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981; 63(6):872–877.
  8. O’Neil OR, Morrey BF, Tanaka S, An KN. Compensatory motion in the upper extremity, after elbow arthrodesis. Clin Orthop Relat Res. 1992; (281):89–96.
  9. Nagy SM III, Szabo RM, Sharkey NA. Unilateral elbow arthrodesis: the preferred position. J South Orthop Assoc. 1999; 8(2):80–85.
  10. Presnal BP, Chillag KJ. Radio-humeral arthrodesis for salvage of failed total elbow arthroplasty. J Arthroplasty. 1995; 10(5):699–701. doi:10.1016/S0883-5403(05)80220-7 [CrossRef]
  11. Rashkoff E, Burkhalter WE. Arthrodesis of the salvage elbow. Orthopedics. 1986; 9(5):733–738.
  12. Tang C, Roidis N, Itamura J, Vaishnau S, Shean C, Stevanovic M. The effect of simulated elbow arthrodesis on the ability to perform activities of daily living. J Hand Surg Am. 2001; 26(6):1146–1150. doi:10.1053/jhsu.2001.28940 [CrossRef]
  13. Steindler A. Reconstructive Surgery of the Upper Extremity. New York, NY: D. Appleton; 1923.
  14. Brittain HA. Architectural Principles in Arthrodesis. Edinburgh: E & S Livingstone; 1942.
  15. Koch M, Lipscomb PR. Arthrodesis of the elbow. Clin Orthop Relat Res. 1967; 50:151–157. doi:10.1097/00003086-196701000-00015 [CrossRef]
  16. Bonnel F. Technique of arthrodesis of the elbow using external fixation. J Chir (Paris). 1974; 107(1):79–82.
  17. Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of Internal Fixation: Techniques Recommended by the AO-ASIF Group. Berlin: Springer-Verlag; 1979. doi:10.1007/978-3-642-96505-0 [CrossRef]
  18. Irvine GB, Gregg PJ. A method of elbow arthrodesis: brief report. J Bone Joint Surg Br. 1989; 71(1):145–146.
  19. McAuliffe JA, Burkhalter WE, Ouellette EA, Carneiro RS. Compression plate arthrodesis of the elbow. J Bone Joint Surg Br. 1992; 74(2):300–304.
  20. Orozco JR, Giros J, Sales JM, Videla M. A new technique of elbow arthrodesis: a case report. Int Orthop. 1996; 20(2):92–99. doi:10.1007/s002640050037 [CrossRef]
  21. Song DJ, Wohlrab KP, Ingari JV. Anterior ulnohumeral compression plate arthrodesis for revision complex elbow injury: a case report. J Hand Surg Am. 2007; 32(10):1583–1586. doi:10.1016/j.jhsa.2007.07.017 [CrossRef]
  22. Vaishya R, Singh AP, Singh AP. Arthrodesis in a neuropathic elbow after posttubercular spine syrinx. J Shoulder Elbow Surg. 2009; 18(4):e13–e16. doi:10.1016/j.jse.2009.01.024 [CrossRef].
  23. Ozer K, Toker S, Morgan S. The use of a combined riblatissimus dorsi flap for elbow arthrodesis and soft-tissue coverage. J Shoulder Elbow Surg. 2011; 20(1):e9–e13. doi:10.1016/j.jse.2010.08.010 [CrossRef]
  24. Reichel LM, Wiater BP, Friedrich J, Hanel DP. Arthrodesis of the elbow. Hand Clin. 2011; 27(2):179–186. doi:10.1016/j. hcl.2011.02.002 [CrossRef].
  25. Preiss RA, Wigderowitz CA. Vascularized fibular graft arthrodesis as salvage for severe bone loss following failed revision total elbow replacement. Eur J Orthop Surg Traumatol. 2011; 21:189–192. doi:10.1007/s00590-010-0686-5 [CrossRef]
  26. Mighell MA, Kovack TJ. Elbow arthrodesis. In: Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Philadelphia, PA: Wolters Kluwer; 2011:3463–3466.

Indications and Contraindications for Arthrodesis

Indication Contraindication
Posttraumatic arthrosis or severe instability Massive bone loss, which may be better treated with an allograft prosthetic composite or intercalated allograft joint reconstruction
Painful pseudoarthrosis Soft tissue loss not amenable to flap reconstruction
Severely comminuted intra-articular fractures of the distal humerus with joint destruction Extensive shortening of the limb is required for fusion, although this may compromise neurovascular structures and alter muscular forces
Chronic osteomyelitis Theoretically, shortening the forearm to achieve fusion may result in altered mechanics of wrist flexors and extensors
Septic and tuberculous arthritis Compromised function of the ipsilateral shoulder, wrist, and spinal column
Complex war injury with large bone and soft tissue defects
Failed internal fixation for nonunion
Sequelae of septic arthritis
Young, healthy laborers with posttraumatic arthritis who are too young for total elbow arthroplasty

Previous Techniques for Elbow Fusion

Technique Year Description
Brittain 1942 Used crossed grafts through the elbow joint
Steindler 1952 Used a single posterior tibial cortical graft keyed into the olecranon
Koch and Lipscomb 1967 Used a modified Brittain procedure in which the tibial graft is placed through a large drill hole in the humerus and ulna, with other cancellous bone grafts added to the joint

Current Techniques for Elbow Fusion

Technique Year Description
Bonnel 1974 External fixator and bone grafting in the presence of an active infection. Useful with large soft tissue defects.
Müller 1979 Combination of axial compression with external fixation and cancellous lag screw
Araflies 1981 Triangular resection of the ulna, fit into a triangular cut of distal humerus. Used with tuberculosis.
Rashkoff 1986 Anterior and posterior plating with autograft
Irvine 1989 Two crossed malleolar screws with autograft
McAuliffe 1992 Use of both posterior and anterior plating with bone grafting
Presnal 1995 Radiohumeral elbow arthrodesis with plating
Orozco 1996 Compression plating with plates and screws
Lerner 2005 Hinged external fixation for patients with significant bone and soft tissue loss
Bilic 2005 External fixation combined with lag screw fixation and bone grafting for war injuries
Song 2007 Anterior ulnohumeral compression after 2 failed posterior ulnohumeral compression plate arthrodeses secondary to soft tissue defect and persistent infection
Koller 2008 Compression plate osteosynthesis and external fixation (3) with an additional humeroulnar lag screw was placed with autograph and occasional double fibular grafting procedure
Vaishya 2009 Radial head excision with posterior plating after posttubercular spine syrinx
Ozer 2011 Combined riblatissimus dorsi flap for elbow arthrodesis and soft tissue coverage
Reichel 2011 A free vascularized fibular graft for massive humeral bone loss with screws placed through the proximal and distal bony interfaces augmented with an external fixator
Preiss 2011 Elbow arthrodesis after failed total elbow arthroplasty with a 12-hole reconstruction plate proximally and with an 8-hole dynamic compression plate distally

Operating Room Setup

Special instruments
  Large fragment 4.5-mm plate (narrow)
  Small fragment 3.5-mm plate (smaller patients)
  Compression vs combination locked plates (depending on bone quality)
  Sterile goniometer
  Plate press
  High-speed burr
  Power drill
  Osteotomes
  Oscillating saw
  K-wire set
Anesthesia
  General anesthesia
  Axillary vs interscalene block
Patient and equipment position
  Antibiotics 30 minutes prior to incision
  Tourniquet for operative side placed as high on the arm as possible. Many patients need a sterile tourniquet.
  Lateral decubitus position with operative arm resting on padded arm rest

Authors’ Recommendations Regarding Their Technique

Step-cut the bone to increase the surface area for healing
Place lag screws in both vertical and horizontal planes to increase compression
Keep dorsal tissue flaps at full thickness, including 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
Never place locking screws prior to reduction and compression of the bone ends
Keep patients casted for a minimum of 4 months, until fusion occurs
  Dependent on radiographs

10.3928/01477447-20140430-04

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