INTRODUCTION

Experience with elbow arthrodesis is often related to injuries seen from military conflict.² Most civilian experience with elbow fusion has come from spontaneous arthrodesis subsequent to infection, trauma, or rheumatic disease of the elbow (Fig. 70-1). One of the prerequisites for elbow fusion is satisfactory function of the shoulder; yet, studies from our laboratory have clearly shown that the increased shoulder motion cannot compensate for loss of elbow motion (Fig. 70-2).¹⁷

FIGURE 70-1 Spontaneous arthrodesis (A) is more common than surgically performed fusion (B) in a civilian population.

FIGURE 70-2 Loss of elbow motion cannot be effectively compensated for by increased shoulder motion, as illustrated by the crescent-shaped space lost by a flexion contracture of the elbow, with normal shoulder motion

Biomechanical and clinical studies have demonstrated that compensatory spinal column and wrist motions are used to improve function after elbow arthrodesis.¹⁷ Thus, limited function (motion) in these areas may be a relative contraindication to elbow arthrodesis. When disease involves both the elbow and the shoulder, arthroplasty must, therefore, be selected. In addition, arthrodesis is not indicated for bilateral elbow disease because the functional limitations are too great. If bilateral arthrodesis is performed, one elbow should be fused in 90 degrees of flexion for personal care and hygiene functions and the other in 45 to 65 degrees of flexion for other uses.^9,17 Functionally, a limited range of 100 degrees in midposition is enough for most daily activities, but removing all elbow motion restricts the majority of necessary daily functions.¹⁴ Hence, some patients request fusion take-down and total elbow even after many years (see Chapter 58).

POSITION

The optimal position for fusion depends on associated joint involvement, gender, the patient’s occupation, or specific functional requirements. Traditionally, 110 degrees is a more functional position.²⁶ For men, 90 degrees of flexion is probably the best position of arthrodesis in a dominant arm that has good shoulder and wrist motion.¹⁶ In this position, the hand can reach the mouth with adaptive neck, shoulder, and wrist motion, and writing may be done comfortably. This has recently been challenged by one recent study suggesting special needs for the nondominant arm may prompt fusion in 30 degrees or 60 degrees of flexion, if, for example, bench work or assistive movements are required.^17,22 If power is not an issue, a position of 70 degrees may be desirable.

INDICATIONS

Because of the limitations mentioned earlier, arthrodesis of the elbow is not often indicated. In fact, although shoulder fusion was employed in 23 of 144 patients with brachial plexus injury, elbow fusion was not preferred in a single patient.²¹ If it has a place in the surgeon’s armamentarium, it is for younger patients with post-traumatic unilateral arthrosis of the elbow who require a strong and stable joint.² In patients older than 45 years who have bilateral disease and limited shoulder or wrist motion, arthroplasty, with or without joint replacement, is preferable. For unilateral postinfectious arthrosis, Rashkoff and Burkhalter proposed plate fixation of contaminated traumatic injuries of the elbow with chronic sepsis.^13,20 Arthrodesis may be difficult to achieve after failed total elbow arthroplasty and is rarely indicated.^11,27 It has yet to be performed at the Mayo Clinic after more than 1700 elbow replacements.

TECHNIQUE

Most of the limited reports on arthrodesis deal with the various techniques.^1,3,11,15,18 The elbow is one of the most difficult joints to fuse surgically. The hand and the forearm act as a long lever arm that produces strong bending forces across the potential fusion site. Success rates have improved considerably with adjunctive internal fixation and intramedullary bone grafting.¹¹

HISTORICAL SURGICAL TECHNIQUES

Steindler²⁵ described a single posterior tibial cortical graft keyed into the olecranon for fusion (Fig. 70-3A). Brittain developed a technique of crossed grafts through the elbow joint^5,7 (see Fig. 70-3B). Noting that gravitational forces tended to compress the ends of the graft, he believed that the crossing of the grafts was important. Koch and Lipscomb¹² have described a modification of this technique in which a tibial graft is placed through a large drill hole in the humerus and ulna, and other cancellous bone grafts are added to the joint.

FIGURE 70-3 A, Steindler technique of elbow fusion. B, Crossed tibial graft technique of Brittain. C, Staples’ technique of elbow arthrodesis.

(A redrawn from Steindler, A.: Reconstructive Surgery of the Upper Extremity. New York, D. Appleton & Co., 1923; B redrawn from Brittain, H. A.: Architectural Principles in Arthrodesis, 2nd ed. Edinburgh, E. & S. Livingstone, Ltd., 1952; C from Staples, O. S.: Arthrodesis of the elbow joint. J. Bone Surg. 34A:207, 1952.)

Staples²⁴ uses a corticocancellous iliac graft through the posterior portion of the elbow and oblique hum-eral and olecranon intra-articular resection (see Fig. 70-3C).

TECHNICAL OPTIONS

Plate Fixation

Spier²³ and Plank¹⁹ have described a compression arthrodesis that makes use of a bent plate and an external compression device (Fig. 70-4). This is also the method favored by Burkhalter¹³ and is probably most commonly used today.¹⁸

FIGURE 70-4 A contoured plate applied posteriorly is the most common technique of elbow arthrodesis today (A). Distal humeral nonunion (B) treated with the posterior plate (Spier’s technique) (C).

(B and C from Spier, W.: Beitrag zur Technik der Druckarthrodese des Ellenbogengelenks. Monatsschr. Unfallheilkd. 76:274, 1973.)

Compression Screws

For post-traumatic arthrosis of the elbow with minimal motion that causes significant pain, we have used compression fixation of the elbow with screws. The procedure involves partial débridement of remaining articular surfaces and compression screw fixation without grafts (Fig. 70-5). Others have subsequently reported on similar techniques.^11,18

FIGURE 70-5 A, Post-traumatic elbow arthrosis. Patient has 10 degrees of painful motion. B, Solid fusion after compression screw application across elbow without bone graft.

For active draining sinuses due to tuberculosis, Arafiles¹ has described a technique that locks the olecranon in the humeral fossa and stabilizes it by screw fixation.

Technique

A straight longitudinal incision is made over the posterior elbow. The triceps tendon is split longitudinally and detached distally for 5 cm with medial and lateral periosteal sleeves. The radial head and both humeral condyles are resected. Complete synovectomy and removal of the articular cartilage is performed. The proximal ulna and the olecranon fossa are shaped into matching triangular sets. After the olecranon is inserted into the trochlea, a single cortical screw is placed from the posterior olecranon and humerus obliquely into the ulna. The flexor and extensor origins are sutured to the triceps fascia, and the triceps is repaired anatomically; the ulnar nerve is transposed anteriorly.

Postoperatively, the patient wears a long-arm cast for 3 months, and then mobilization is allowed. Appropriate drug therapy is initiated preoperatively and continued as necessary through 18 months.

In 13 patients with tuberculosis, he achieved healing within 3 months in all.

EXTERNAL SKELETAL FIXATION

Bonnel³ reported a successful case of elbow arthrodesis (for failed arthroplasty) in which external skeletal fixation was combined with bone grafting (Fig. 70-6). In the presence of active sepsis, synovectomy and débridement of the radial head and articular surfaces, followed by external skeletal fixation allows spontaneous arthrodesis to occur in the desired position. Fixation has also been described with a bilateral trapezoidal frame.

FIGURE 70-6 Fixation of humerus, radius, and ulna with Hoffmann’s device for arthrodesis of elbow.

(From Bonnel, F.: Technique d’arthrodese du coude par fixateur externe. J Chir. [Paris] 107:79, 1974.)

Two transfixing pins are placed in the midportion of the humerus and in the proximal ulna. Care must be taken to avoid the radial and ulnar nerves. Three nontransfixing pins are placed in the midportions of the radius and ulna, and the trapezoidal configuration is completed.⁶ There is, however, no single arrangement that must be followed; rather, the design is dictated by the lesion, especially by the amount of bone fusion (Fig. 70-7).

FIGURE 70-7 A, Unstable elbow after débridement for chronic draining Pseudomonas osteomyelitis in a steroid-dependent rheumatoid arthritis patient. B, Two months after application of a bilateral triangular frame. Wounds were left open and healed per primum. Bony arthrodesis is occurring. C, Bilateral triangular frame of the type seen in A and B for an unstable and infected elbow.

Combination: AO Compression

When possible, axial compression with external fixation coupled with a cancellous lag screw placed into the humeral shaft is an attractive blend of concepts (Fig. 70-8). Through a posterior approach, the surfaces of the distal humerus and olecranon are resected to provide a wedge fit. The radial head is excised, and a Kirschner wire is passed from the olecranon up the humeral shaft. Transverse pins are inserted through the olecranon and humerus, the Kirschner wire is removed, and a long, cancellous screw is inserted with a washer up the shaft of the humerus. External compression clamps are then applied.

FIGURE 70-8 The AO technique of axial fixation and external skeletal fixation for arthrodesis of the elbow.

(Redrawn from Muller, M. E., Allgower, M., Schneider, R., and Willenegger, H.: Manual of Internal Fixation: Techniques Recommended by the AO-Group, 2nd ed. Berlin, Springer-Verlag, 1979.)

AUTHOR’S PREFERRED METHOD OF TREATMENT

COMPLICATIONS

Nonunion

Few data are available about success rates for primary arthrodesis. Koch and Lipscomb reported that primary arthrodesis failed in nine of 17 patients treated at the Mayo Clinic.¹² Six of 11 elbows treated for tuberculosis failed to unite. Extensive joint destruction and unavailability of chemotherapy were cited as contributory factors to this poor rate of fusion. A recent updating of the Mayo Clinic experience has demonstrated a significant decrease in nonunion rates with internal fixation. Hahn documented six of six fusions with a combination of internal and external fixation but only five of nine fused when external fixation alone was used.¹⁰

Fracture

The long lever arm created by elbow fusion increases stress along the entire extremity. Fracture through or proximal to the fused or ankylosed joint is not uncommon and was reported in four of 17 patients by Koch and Lipscomb.¹² Conservative treatment, however, usually results in union (Fig. 70-9).

FIGURE 70-9 A, Fracture below elbow arthrodesis. B, Rapid healing with simple immobilization.