Chronic Unreduced Elbow Dislocation

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CHAPTER 30 Chronic Unreduced Elbow Dislocation

Bernard F. Morrey

INTRODUCTION

Elbow instability in one form or another remains one of the most vexing of all expressions of elbow trauma. The spectrum of elbow instability is carefully addressed in the pediatric patient (see Chapter 20), simple and complex instability in the adult (see Chapters 28 and 29), and in the chapter on external fixation for the elbow (see Chapter 33). The instability addressed in this chapter is termed chronic unreduced complete dislocation. A chronic unreduced dislocation is very uncommon in this country and is principally seen in Third World nations. Thus, much of our understanding has come from contributions from South Africa, Thailand, and India.^8,^10,^11,^14,^17,¹⁸

CHRONIC UNREDUCED ELBOW JOINT

The simplest way to consider the two major types of chronic unreduced elbow joints is that of subluxation, or complete dislocation. The most common of these is sometimes a subtle chronic posterior subluxation due to fracture of the coronoid. This chronic instability pattern is dealt with in the chapter on complex instability (see Chapter 29). The chronically unreduced complete dislocation is not common, so few have much experience dealing with it. The second is an unreduced complete dislocation, which is rare except, as mentioned earlier, in underdeveloped countries.

PRESENTATION

Chronic unreduced complete dislocation has the following characteristics: (1) gross deformity; (2) variable motion from complete ankylosis in approximately one third of cases to a near-functional arc of motion of greater than 40 degrees in one third, and motion between 0 to 40 degrees in the remaining one third ¹³; (3) pain ranges from minimal to significant depending on the duration of the dislocation with marked individual variation.

OCCURRENCE AND CLINICAL PRESENTATION

At presentation, about two thirds have unacceptable function due to instability, pain, or both.¹³ The frequency is highly dependent on the local medical customs dealing with the initial dislocation, experience, expertise, and expectation. The presence of traditional medical care (bone setters³) explains the reports from Africa documenting large series (81 cases over a 10-year period).¹⁴ In Thailand, 135 patients were reported in a 15-year period from three hospitals.¹⁰ The deformity may occur both in children and in adults. These patients have often sustained an associated fracture as well. Naidoo¹⁴ noted that 13 of 23 patients undergoing treatment had an associated fracture. A similar rate of 45% (62 of 135) was reported from a large multicenter study by Mahaisavariya and associates.¹⁰ About 50% simply have a posteriorly displaced, complete dislocation. The patients usually do not have neurologic deficit at the time of presentation, but if there is neural impairment, the ulnar nerve is most commonly symptomatic. Vascular compromise is extremely rare.

TREATMENT

The choice of treatment has been predicated on the age of the patient, the timing of the intervention, and the likelihood of successful reduction. The full spectrum of reconstructive options has been suggested as a treatment for the neglected dislocation. These options include reduction, reduction and interposition, resection, fusion, and replacement. Resection is not a viable option today. In most practices and circumstances, fusion might be considered, but this is not usually considered in the United States. The techniques of interposition and replacement arthroplasty are discussed elsewhere (see Chapters 69 and 70). An attempt at closed reduction is reasonable at all ages for dislocations of less than 3 weeks’ duration. Today, this is particularly effective with the added stability provided by an external fixation.^9,¹⁸ Although fusion and resection have both been considered for the chronic condition,^2,^4,⁶ by far the most logical and accepted approach is open reduction (Fig. 30-1). Although this recommendation has been somewhat controversial in the past, open reduction outcomes are as good or better than other options and is effective years after injury.^5,¹¹

FIGURE 30-1 A, Chronic unreduced dislocation of 4 months’ duration. B, Treated in the manner described with external fixator. C and D, Well reduced and functional with a 105-degree arc of motion 1 year later.

Here we will review only the treatment strategy for open reduction. The use of an external fixation is discussed in Chapter 33. Joint replacement is recommended in patients older than 60 years of age and is discussed in Chapter 59. The surgical approach is predicated onan understanding of the pathology and a flexible surgical treatment plan.

PATHOLOGY

The rationale and surgical strategy is predicated on recognizing, anticipating, and treating each element of the pathology encountered. The pattern is rather consistent: (1) a contracted triceps tendon; (2) contracture of the medial and lateral collateral ligaments; (3) variable involvement of the ulnar nerve; (4) contracted anterior and posterior capsules; (5) fibrous membrane covering the articular surface; and (6) commonly, (30% to 40%) an associated fracture of the coronoid or radial head, or both.

SURGICAL TECHNIQUE

The surgical technique preferred by the author specifically addresses the pathology according to a defined sequence (Fig. 30-2).

1. A posterior skin incision is made. With gross deformity, the subcutaneous border of the ulna is identified as the distal landmark and the midportion of the humerus as the proximal landmark. An incision over these two landmarks is then joined to provide a straight incision after the deformity has been corrected (see Fig. 30-2A).

2. The dissection is carried medially to the ulnar nerve, which is identified and released to its first motor branch. A subcutaneous pocket is developed (see Fig. 30-2B).

3. The dissection is carried laterally to the lateral epicondyle. Kocher’s interval is entered, and the radial head exposed. The lateral column of the humerus is exposed proximally.

4. The lateral collateral ligament and extensor mass are elevated from the lateral epicondyle (Fig. 30-2C). The dense adhesions that are consistently present are then released from the articular surface between the ulna and humerus, and the radius and the humerus. The lateral contracted tissue is the limiting factor in preventing relocation, so this is aggressively released, including the extension origin, and the distal fibers of the brachioradialis muscle. The greater sigmoid notch is cleaned.

5. The posterior capsule is completely released (see Fig. 30-2D).

6. The anterior capsule is excised.

7. The medial collateral ligament is contracted, and if this prevents relocation, it is then completely released from the medial epicondyle.

8. The elbow is gently manipulated so as to reduce the radial humeral and ulnohumeral articulations (see Fig. 30-2E). Note: At this point, it is important that the joint rest in the reduced state without significant external force.

9. If the joint surface is destroyed, we interpose an Achilles allograft tendon. If the collateral tissue is inadequate for repair, we use a portion of the tendon for ligamentous reconstruction.

10. The lateral collateral ligament and, if necessary, the medial collateral ligaments are repaired with No. 5 Mersilene sutures placed through the ligament in a Bunnell fashion and attached to the anatomic origin through bone holes (see Fig. 30-2F). Note: If the tissue is inadequate, a plantaris allograft is used to reconstruct the deficient tissue. If both ligaments require reconstruction, we use a simple allograft and “sling” the ulna to the humerus by connecting the medial and lateral humeral origins of the medial and lateral ulnar insertion sites.

11. Triceps repair. Management of the triceps is one of the most controversial issues of this treatment.¹⁰ The elbow is flexed to assess the influence of the contracted triceps. If the elbow can be flexed to 110 degrees, no triceps reconstruction is performed because it is believed that the musculotendinous complex will stretch out in time. If less than 100 degrees of flexion is possible, a tricepsplasty is performed. The anconeus is elevated from the bed. The anconeus and triceps are then repositioned over the tip of the olecranon, and with the elbow in 90 degrees of flexion, it is reattached with nonabsorbable No. 5 suture.

12. An external fixator is applied because it is essential to allow immediate motion and to preserve the collateral ligament reconstruction (see Chapter 33) (see Fig. 30-2G).

FIGURE 30-2 A, Posterior incision is employed by using the subcutaneous border of the ulna distally and the midportion of the humerus proximally. The ends of each incision are joined to ensure proper orientation of the final incision for those with gross deformity. B, Medial and lateral flaps are elevated, and the ulnar nerve is released. C, The lateral contracted ligament and extensor mechanism (A) is first released from the humerus followed by medial collateral ligament release (B) from the humerus if necessary. D, The joint is cleared of membrane, and the posterior and anterior capsules are resected. The triceps is elevated from the humerus. E, The joint is manipulated and reduced. F, The collateral ligaments are repaired. G, The construct is stabilized with dynamic external fixation, and the axis pin is removed.

POSTOPERATIVE MANAGEMENT

The arm is elevated for 24 hours, after which continuous passive motion (CPM) is used. The patient returns home in a portable CPM with as much motion as tolerated. The external fixator is maintained for 3 to 4 weeks. The patient then returns to the hospital, and under a brief general anesthesia, the external fixator is removed and the elbow examined under fluoroscopy (see Chapter 33). Flexion and extension splints are then used to establish and maintain an arc of functional motion (see Chapter 11).

RESULTS

Naidoo ¹⁴ described a satisfactory result in 23 of 25 patients treated in a manner similar to that just described but without a fixator. Arafiles¹ described a satisfactory outcome in 11 of 12 surgical procedures. Open reduction was reported as successful in 72% of 52 patients by Di Schino and associates.⁵ Interestingly, these investigators also found complete resection of the elbow for the chronic cases to be successful in 80% of cases.⁴ However, careful interpretation of these two reports suggests that these authors are referring to improvement of motion and admitted that the resected elbow was weak and had marked instability, and hence, they favor reduction over resection.

MOTION

The improvement is marked, but a functional status is not always attained. Of the 23 patients reported by Naidoo ¹⁴ with 13 associated fractures, eight patients remain with less than 60 degrees of motion (33%). Five had an arc of motion between 60 and 90 degrees (20%), and 10 (40%) had an arc of motion greater than 90 degrees. Naidoo also demonstrated that the overall outcome was not a function of age or duration of dislocation as had been previously thought. On the other hand, Arafiles¹ reports a mean of 105 degrees arc at 2 years in a group of 11 patients. The most recent report from Bangkok documented a final arc of flexion of 82 degrees in 24 patients 4 years after surgery.¹¹

One major discussion in the literature relates to the management of the triceps. If operated on less than 3 months after injury, this generally need not be lengthened or addressed. However, as mentioned earlier, if the triceps is badly contracted and limits flexion, then some form of triceps augmentation and release is appropriate. Mahaisavariya and colleagues ¹⁰ demonstrated that leaving the triceps intact was associated with increased motion (P > .05) of 115 degrees in those in which the triceps was not altered, compared with 89 degrees in those with triceps release. In addition, they demonstrated that the flexion contracture was markedly greater (by 70 degrees) in those with a tricepsplasty, compared with 45 degrees in patients in whom tricepsplasty was not carried out. If the triceps is addressed, V-Y lengthening as described by VanGorder has been suggested by some; however, as noted earlier, we prefer the anconeus slide technique. Overall, this approach has been effective even in those with considerable joint deformity (Fig. 30-3A to G)

FIGURE 30-3 A, Established chronic elbow dislocation of 5 years’ duration. B, An Achilles tendon allograft fashioned in a way to preserve the margins as “tails” used to reconstruct the collateral ligaments. C, The elbow is reduced and the Achilles allograft is draped over the joint. The tissue to reconstruct the medial and lateral collateral ligaments have been fashioned. D, Each portion of the allograft is brought through a tunnel connecting the sublime tubercle and the supinator crest. This forms a “sling” of reconstruction. E, The external fixator has been applied. Note that the elbow is reduced. F, Note that the patient has freedom of flexion and extension in the external fixator. G, One year after surgery the elbow remains reduced with an arc of motion of 35 to 125 degrees and minimal pain. The patient is well pleased with the outcome.

COMPLICATIONS

This is difficult surgery, and as might be expected, this type of injury and surgery are associated with significant complications. Transient nerve injury has been reported in 8% to 40% of cases.^7,¹⁴ Infection occurs in approximately 5%.¹ Ectopic bone was reported in none of the 70 cases of Mahaisavariya and associates¹⁰ and none of the 23 cases of Naidoo.¹⁴ On the other hand, it was observed in 8% of the patients reported by Fowles and colleagues⁷ and one in four of the patients described by Billett.³ The overall complication rate is approximately 20% to 25%. Complications that significantly affect the outcome occur at a rate of at least 10%.