Interposition Arthroplasty of the Elbow

Published on 12/04/2015 by admin

Filed under Orthopaedics

Last modified 22/04/2025

Print this page

This article have been viewed 6943 times

CHAPTER 69 Interposition Arthroplasty of the Elbow

Bernard F. Morrey, A. Noelle Larson

INTRODUCTION

In my practice, interposition arthroplasty is assuming an ever-increasing relevance as we continue to struggle to develop alternatives to prosthetic replacement in the younger patient. Since the last edition, we have improved our technique, and possibly our results.

HISTORICAL ASPECTS

The so-called functional arthroplasty, popularized by Hass (1944),¹¹ might be considered the predecessor of interposition arthroplasty. Functional arthroplasty is actually a variation of resection arthroplasty, except that the distal humerus is fashioned in the shape of a wedge and various types of interposed tissues may be inserted (Fig. 69-1). Hass reported a long-term satisfactory result of 73% in 15 patients, with an average follow-up period of 5.5 years. Because this is a type of resection arthroplasty, it is not surprising that 13 of the 15 procedures were in patients with previous infection.

FIGURE 69-1 The so-called functional or anatomic arthroplasty resects variable amounts of distal humerus but fashions the bone as a fulcrum against which the proximal ulna pivots. Skin and other substances can be used to cover the humerus and create a new articular surface; hence, the term interposition arthroplasty.

Interposition arthroplasty has been used for treatment of arthritis involving the temporomandibular, shoulder, wrist, knee, and hip joints. Of these, the elbow has been reported as second only to the temporomandibular as the joint most amenable to the technique.¹³ In Europe, arthroplasty was popularized by Putti³⁰ and by Payr.²⁸ Schüller was the first to recommend the procedure for patients with rheumatoid arthritis.³² Various muscle flaps, pig bladder,² fascia-fat transplants, skin, and other materials have been used as the interposing agent. In 1902, Murphy introduced and popularized arthroplasty in the United States.^26,²⁷ Lexer,²¹ in 1909, emphasized the value of autogenous tissue and confirmed the impression of Murphy²⁷ that fat and fascia were the best substances for interposition arthroplasty. He reported that fascia remained viable and was replaced by fibrous and fibrocartilaginous tissue. The observation has not been subsequently confirmed, rather the joint appears to be comprised primarily of fibrous tissue.²⁹

OUTCOMES

Autogenous or xenograft cutis has been used as an interposing membrane in resection arthroplasties (cutis arthroplasty) of various joints since 1913, and successful use in the elbow has been reported by several authors.^9,^16,²⁴ Cutis is the thick dermal layer of skin that remains after the superficial epidermal layer has been removed. It is a tough, durable, elastic membrane, and it closely adheres to the cut surface of the distal humerus.

Fascia lata is easy to harvest and conforms readily to the bony surfaces, but the donor site leaves variable morbidity. Efforts to enhance its effect have been reported by Kita ¹⁷ using chromicized fascia lata, the so-called J-K membrane.

In 1979, Shahriaree and colleagues ³³ reported that of 30 patients, 90% returned to their previous occupations after excisional arthroplasty with Gelfoam interposition. Smith and associates³⁴ successfully used silicone sheets as interposition material in six patients with hemophilic arthropathy.

In recent years, the concept has been reassessed with the addition of three important features to the technique: distraction, motion, and large allograft interposition.

INDICATIONS

BASIC CONCEPTS

For the young individual who has lost the use of the elbow, avoidance of arthroplasty is desirable. Alternative recommendations include (1) no surgical treatment and altered activity, (2) orthotics for the unstable elbow, (3) arthrodesis, and (4) interposition (distraction) arthroplasty. Resection arthroplasty is rarely, if ever, indicated at this time, the only indication being uncontrollable infection with inadequate bone to allow an ulnohumeral fulcrum.

If the elbow is ankylosed in a functional position, no treatment may be required. If it is ankylosed in a poor position, osteotomy with correction of the position may be considered. If the patient has mildly painful motion or a minimally unstable elbow, an orthotic brace may allow continuation of activities until progression dictates definitive treatment. The individual who is required to carry out strenuous activities may not be a suitable candidate for any type of arthroplasty.

INTERPOSITION

Specific Indications

The basic indications for interposition arthroplasty are either incapacitating pain or loss of motion in an individual younger than 40 years of age with rheumatoid arthritis, and younger than 60 years of age with traumatic arthritis. Loss of motion may follow trauma, sepsis, burns, or degenerative or inflammatory arthritis. However, the most compelling indication for arthroplasty of the elbow is incapacitating functional loss. If the loss of motion and pain are postinfectious, careful evaluation must be done to ensure that the patient has been free of the infection, preferably for at least 1 year. The best indication for this procedure is post-traumatic, painful loss of motion not complicated by sepsis in an individual who does not require long-term heavy demand on the joint.²⁵

In addition to the specific pathology, selection of the proper candidate for interposition arthroplasty largely depends on patient needs and expectations, and whether alternatives exist.

CONTRAINDICATIONS

If recent sepsis has occurred, other than débridement, reconstruction should not be considered. If epiphyseal closure has not occurred, arthroplasty should be delayed until growth is complete. In the past, a major contradiction to interposition arthroplasty was inadequate bone stock. Grishin and colleagues,¹⁰ however, have reported using interposition arthroplasty in conjunction with reconstructive bone grafts for marked osseous deficiency.

We have found gross instability, deformity, and marked pain, especially at rest, are all associated with poorer outcomes.^8,^20,²⁵ The patient with a grossly unstable elbow from rheumatoid or post-traumatic arthritis cannot be adequately stabilized by an interposition procedure. Congenital ankylosis of the elbow joint that lacks the necessary ligamentous support may be treated with interposition and ligamentous reconstruction. However, the absence of flexion motor power is an absolute contraindication to this procedure. The need to use the upper extremity in ambulation or for transfer from bed to chair is a relative contraindication because excessive loading of the elbow destabilizes the joint.

If the patient is a heavy laborer, interposition arthroplasty may not be as satisfactory as a painless arthrodesis of the elbow in a functional position. Although interposition arthroplasty offers the patient a relatively pain-free durable joint, it cannot guarantee enough stability to allow for the activities of heavy labor. If multiple joints in the same extremity have become ankylosed, it will be more difficult to secure a satisfactory result.

Finally, it is of utmost importance that the patient have the motivation and fortitude to participate in a preoperative and postoperative rehabilitation program for proper rehabilitation of the musculature of the upper extremity.

PREFERRED TISSUE

Autogenous skin and fascia and achilles tendon allografts have all been used by the senior author. The cutis is very durable and thick, rapidly adheres to the bone, and has generally been successful.^4,^7,⁹ The harvest techniques are attractive in those patients in whom primary closure may be carried out. Cutis tissue without the epidermis is somewhat more difficult to harvest. Fascia is also commonly used because it is readily available from the thigh and can be overlapped to ensure adequate bulk.^18,²⁵ Recently other processed tissues such as AlloDerm (LifeCell, Branchburg, NJ) are being investigated for this purpose.¹² At present, we prefer the achilles tendon allograft because it is readily available. The following anatomic features are required for success of the procedure: absence of donor site morbidity, large size and thickness, sufficient material for ligament reconstruction if necessary, and presence of calcaneus if osseous graft is required.

PREFERRED TECHNIQUE—ACHILLES TENDON ALLOGRAFT

Herein we describe our current exposure, preparation, graft insertion, and closure. The technique may be used for any tissue.

SURGICAL TECHNIQUE

The patient is positioned supine with a pneumatic tourniquet in place. A posterior incision is preferred, although a pre-existing incision is reopened if consistent with the needed deep exposure. In all instances, the ulnar nerve is identified, mobilized, and protected throughout the case. The nerve is transposed subcutaneously if it is found to subluxate at the completion of the surgery. Kocher’s interval is developed between the anconeus and extensor carpi ulnaris. The lateral collateral ligament (LCL) complex and the common extensor muscles are released from the lateral condyle of the humerus. Anterior and posterior capsulectomy is performed to obtain useful elbow motion (Fig. 69-2). The tip of the olecranon is removed if it is prominent. The triceps muscle is elevated from the lateral distal humerus, and the anconeus mobilized from its ulnar attachment. The lateral one half of the triceps attachment is released from the olecranon, and the extensor mechanism is inserted as the forearm is flexed and supinated. If the cartilage appears beyond salvage, then the decision is made to proceed with interposition arthroplasty. The ulnar and humeral surfaces are prepared with a rongeur, burr, or semicircular saw to obtain a congruent articulation (Fig. 69-3). Care is taken to avoid resection of the subchondral bone, which may lead to excessive bony resorption, although the medial and lateral trochlear ridges are removed if necessary to obtain a smooth articulation. Sufficient bone is resected from the ulnar and humeral articular surfaces to accommodate at least 2 to 3 mm of joint space laxity even after insertion of the tendon to avoid “overstuffing” the joint.

FIGURE 69-2 A, Kocher’s interval is entered through a posterior skin incision. The triceps is elevated posteriorly from the humerus, whereas the extensor mechanism is elevated anteriorly. Typically, approximately a third to a half of the triceps attachment is removed from the olecranon in order to afford adequate exposure for insertion of the interposition tissue. B, The lateral collateral ligament is released along with the anterior and posterior capsules.

FIGURE 69-3 The distal humerus has been exposed. The lateral collateral ligament has been preserved. The ulnar nerve has been anteriorly translocated (left). Preparation of the distal humerus preserves the subcondral bone. Through-and-through drill holes are placed to receive the graft (right).

Graft Application and Ligament Reconstruction

A fresh-frozen Achilles tendon allograft is our current preference (Fig. 69-4). Three or four drill holes are made across the distal humerus (see Fig. 69-3). Using a horizontal mattress stitch, the graft is sutured to the distal humerus through the drill holes (Fig. 69-5). The ulnohumeral joint is then reduced, and the integrity of the medial collateral ligament (MCL) is assessed. The smoothness of the articulation and elbow range of motion are determined. If adequate tissue is present, the lateral collateral ligament is repaired primarily. If the tissue is inadequate, reconstruction of the remaining portion of the ligament is carried out with the allograft tendon (Fig. 69-6). In cases in which both lateral and medial collateral ligaments are intraoperatively found to be deficient, a tunnel is drilled through the distal humerus, replicating the axis of rotation at the ulna. A second tunnel connects the sublime tubercle and the tubercle of the crista supinatorus. The distal strands of the allograft are threaded through the humeral tunnel and ulnar tunnels to create a “sling” simultaneously to reconstruct both the MCL and LCL (Fig. 69-7). The sling is hand-tensioned to maintain joint stability but still allow for smooth flexion and extension across the articulation. Following the reconstruction, the elbow is again taken through a range of articulated motion and tested for stability.

FIGURE 69-4 An Achilles tendon allograft with sutures in place ready to be placed over the distal humerus preserves the subchondral bone

FIGURE 69-5 The Achilles tendon allograft has been placed over the distal humerus. Two of the three sutures that secure the graft are in place

FIGURE 69-6 An extension of the lateral aspect of the Achilles tendon graft is preserved, brought over the lateral aspect of the distal humerus, and anchored to the anatomic origin of the lateral ulnar collateral ligament

FIGURE 69-7 In instances in which both collateral ligaments have been deficient, the “tails” of the Achilles tendon graft are harvested to reconstruct the medial and lateral collateral ligaments. A single drill hole connects the ulna attachment of these two ligaments as shown. Under these circumstances, the construct is always protected with the external fixator.

EXTERNAL FIXATION

Standard treatment today involves placement of an external fixator (DJD I or II Dynamic Elbow Joint Distractor, Stryker, Kalamazoo, MI). This device may be applied without damage to any collateral repair or reconstruction (Fig. 69-8). The fixator is intended to maintain stability and to distract or separate the joint, allowing for motion while protecting the interposition and the ligament reconstruction to allow for proper healing. In some instances, because of patient preferences, geographic distances rendering follow-up impractical, or surgeon’s intraoperative judgment, the fixator is not applied.

FIGURE 69-8 A, The external fixator is applied using a stylus to simulate the axis of rotation. The stylus prevents injury to the reconstructed collateral tissue. B, The ulna is separated from the humerus in order to allow motion while protecting against shearing forces on the interposed tissue, allowing it to securely heal to the humerus. Excellent flexion (C) and extension (D) motion is expected.

Aftercare

Patients are treated with continuous passive motion in the hospital for a mean of 2.3 days, typically with an axillary block for regional pain control. Today patients are routinely dismissed home on postoperative day two. At a mean of 30 to 35 days postoperatively, the patient returns for removal of the external fixator under anesthesia. The elbow is gently “examined” for stability and smoothness of the articulation, as well as being taken through a range of motion. No forceful maneuvers were employed, but the flexion and extension limits are stretched at this time. Mean range of motion obtained at the examination under anesthesia is about 115 degrees.¹ Patients with persistent stiffness are prescribed static adjustable flexion and extension splints to be worn 23 hours per day for 3 weeks to maintain the range of motion obtained at the examination under anesthesia. Maintenance bracing is continued for 8 to 12 weeks. No dynamic splinting is used, and no patient is treated with formal physical therapy.

CUTIS ARTHROPLASTY

HARVEST AND APPLICATION

Options

The senior author uses the cutis for limited interposition such as for radiohumeral arthritis. Froimson and associates ⁹ have described a more extensive harvest and application. If fascia is to be used, we favor folding the graft into a three-ply construct (Fig. 69-9).

FIGURE 69-9 The tissue is attached by through-and-through sutures across the distal humerus. If fascia is used, a three-ply composite is used and is attached as shown

CUTIS HARVEST—FROIMSON

Using a hand-held or motorized dermatome, remove a thin split-thickness skin graft from the patient’s lower abdomen, leaving a standard split-thickness donor site with punctate bleeding. With a sharp knife, remove this deep dermal layer with minimal subcutaneous fat (Fig. 69-10). Secure hemostasis with electrocautery and use the split-thickness graft to cover the donor site.

FIGURE 69-10 Froimson technique for harvesting cutis arthroplasty from the lower abdomen. This does require a skin graft to be placed over the cutis donor site. This graft is usually obtained from the thigh

LIMITED HARVEST—MORREY

An alternative method to harvest a limited graft has been developed. An elliptical pattern is placed in the bikini line (Fig. 69-11). Linear incisions just through the epidermis are made every 3 to 4 mm. The dermis is elevated leaving the cutis, which is sharply excised. The wound is closed primarily. This has the advantage of being a relatively quick procedure with a more pleasing scar at the donor site.

FIGURE 69-11 The Morrey technique harvests a limited amount of cutis tissue in the bikini line (A). Thin strips of dermis are removed, allowing the cutis to then be excised. The donor site is closed primarily (B).

APPLICATION

Attach the cutis graft to the prepared end of the distal humerus as described earlier.

RESULTS

HISTORICAL

Early reports of fascial arthroplasty by Campbell,^5,⁶ Henderson,^13,¹⁴ and MacAusland and MacAusland²³ showed that excellent or good pain relief and improvements in motion and function were obtained in about 75% of patients. In 1940, Speed and Smith³⁵ noted that the best results could be obtained in patients between the ages of 18 and 40 years. In 1952, Knight and Van Zandt¹⁸ reported 56% good and 22% fair results in 45 patients an average of 14 years after fascial arthroplasty. Their best results were obtained in patients between the ages of 20 and 50 years. Most patients regained motion between 6 months and 6 years after surgery, and maximum strength was obtained at about 1 year. In 1967, Vainio³⁷ reported that more than half of 131 patients undergoing fascial arthroplasty for rheumatoid arthritis were free of pain and had more than 90 degrees of flexion.

Subsequent reports have supported the value of fascial arthroplasty of the elbow in well-selected patients.^9,^16,^24,³⁶ Kita¹⁷ reported the use of a chromicized fascial interposition material in 31 patients in an attempt to reduce the inflammatory response initiated by fascia lata. At 19-year follow-up, half of his patients had excellent or good results and 20% had poor results. Uuspaa³⁶ reported improved range of motion and decreased contractures after 51 cutis arthroplasties in 48 patients with rheumatoid arthritis; these patients ranged in age from 25 to 69 years. In a recent review of cutis arthroplasties in 14 patients ranging in age from 26 to 51 years, motion and medial-lateral stability were satisfactory in all.²¹ Although the technique is favored for rheumatoid arthritis in Europe, both rheumatoid and traumatic conditions are available to interposition arthroplasty if the proper indications are met (see Figs. 69-7, 69-8, and 69-12).

FIGURE 69-12 A, Radiographic appearance of an elbow with post-traumatic arthritis. B, Radiographic appearance following fascial arthroplasty; left, extension; right, flexion. C, Flexion 5 years following surgery. D, Extension 5 years following surgery.

Little correlation between the final radiographic appearance of the elbow and the functional result is accepted. Range of motion and stability of the arthroplasty are best in patients with good periarticular structures and good elbow flexor and extensor musculature.

CURRENT EXPERIENCE

Rüther and colleagues ³¹ recently reported the results of 61 procedures for rheumatoid arthritis and using dura mater, 17 of which were followed for less than 5 years, 52 between 5 and 10 years, and 12 for more than 10 years. Overall, 69% were satisfied and 70% had no or minimal activity restriction. Generally good results were reported in 14 with rheumatoid arthritis and followed 12 years after autogenous triceps fascial interposition.²⁴ Ljung and associates²² described the results of 35 procedures using bovine cutis interposition and followed a mean of 6 years. Although 21 of 28 (75%) were pain free, functional limitation, especially instability, prompted the authors to recommend elbow replacement as the treatment of choice.

MAYO EXPERIENCE

The initial experience was focused on a group of 60 patients with stiffness as the primary diagnosis.²⁵ The concept of an aggressive soft tissue release, interposition with fascia lata and protection using an external fixator was introduced. With a follow-up of more than 5 years, more than 80% of patients were satisfied with the procedure. The arc of motion increased from a mean of 30 degrees to 90 degrees (Fig. 69-13).

FIGURE 69-13 Results after distraction interposition arthroplasty in patients with preoperative stiffness

In a subsequent study of 13 patients with traumatic arthritis but good motion (>80 degrees), Cheng and Morrey ⁸ documented 75% satisfactory results using fascia lata, a mean of 5 years (range, 2 to 12 years) after surgery. It is of note that those without pre-existing instability revealed 80% satisfactory outcomes. Those with residual instability had a 50% unsatisfactory outcome (Fig. 69-14).

FIGURE 69-14 A and B, Preoperative radiograph of 32-year-old woman with rheumatoid arthritis. Her preoperative arc of flexion was 45 degrees. C and D, Six and a half years after surgery, the patient has minimal pain with an arc of motion of 30 to 125 degrees. She is satisfied with the procedure.

MAYO RECENT EXPERIENCE

Our experience has recently been updated by Larson et al.²⁰ Between 1996 and 2003, 69 consecutive elbows underwent interposition arthroplasties, all with an achilles tendon allograft. A hinged external fixator was used postoperatively in two thirds of these patients. Overall, the patient population was young, averaging 39 years. About 25% were for inflammatory and 75% had post-traumatic arthritis. Details are available in 45 patients. The mean time to clinical follow-up was 6.0 years (range 2.9 to 10.5 years). Seven patients subsequently underwent revision surgery: two infection cases, two instability cases, one elbow arthrodesis for instability, and two elective total elbow arthroplasties.

In the thirty-eight patients with surviving allografts, the flexion-extension arc improved from a preoperative mean of 51 degrees to 97 degrees following surgery (P < 0.001, matched pairs analysis). Mean preoperative MEP score was 42 points, improving to a mean of 65 points postoperativeloy (P < 0.001), matched pairs analysis) (see Fig. 69-14). Only 30% demonstrated a satisfactory MEPS, however, subjectively 88% would repeat the procedure. Despite efforts to reconstruct collateral ligaments, preoperative instability on physical examination was associated with low MEPS (P = 0.03), and high DASH scores¹⁵ (P = 0.006, Fisher exact test) postoperatively when compared to patients with no preoperative instability. On the other hand, a well-balanced interposition procedure can last up to 20 years (Fig. 69-15).