Arthrodesis of the elbow

Elbow Interposition Arthroplasty With Meniscal Allograft

Painful, end-stage elbow arthritis in young, active patients remains a challenging and unsolved problem. Lifetime weight-bearing restrictions make total elbow arthroplasty (TEA) an unrealistic and unsustainable option for most of these patients, and the alternatives for treating a failed TEA are limited and mostly unsatisfactory. Elbow interposition arthroplasty can provide good pain relief and reasonable restoration of motion while avoiding weight-bearing restrictions. However, resurfacing materials such as fascia, Achilles tendon, and skin are not durable and are likely torn or displaced. We propose using meniscus allograft as the interposition material, as it is strong, robust, and designed to resist high compressive and shearing loads. It can heal the native tissue, and the topological properties of an amphitheater-shaped meniscus wrapped in a semicircle anatomically simulates the native shape of the trochlea, conferring additional stability that abets concentric motion. We present a series of 5 patients who underwent meniscal allograft arthroplasty from 2021 to 2023 at a single institution. All patients had resurfacing with meniscus allographs with supplemental stabilization using a double internal joint stabilizer. All patients demonstrated improvement in pain and ulnohumeral range of motion. Our technique of meniscus allograft interposition arthroplasty demonstrates good short-term pain relief and functional improvement. Further follow-up is warranted to assess the longevity of the meniscus interposition. Level of Evidence: Level IV-treatment study.

Surgical management of osteoarthritis in the shoulder and elbow

Interesting recent trends are apparent in the setting of shoulder and elbow pathology. There is an increase in utilization of shoulder arthroplasty for osteoarthritis and post traumatic arthritis. At the same time, there remain limited options for osteoarthritis of the elbow particularly in the young and or active patient. This manuscript details surgical options for osteoarthritis at the elbow and shoulder.

Elbow Arthrodesis Surgical Technique

Elbow arthrodesis is an uncommon salvage procedure indicated for failed total elbow arthroplasty, segmental bone loss near the elbow, and severe postinfectious or posttraumatic arthritis. This video demonstrates the surgical technique for elbow arthrodesis in a patient with segmental bony defect of the ulna and postinfectious and posttraumatic elbow arthritis after a severe left arm degloving injury with Monteggia fracture dislocation and radial head fracture.

Ulna Fractures After Elbow Arthrodesis: A Report of 3 Cases

CASE

Two surgeons performed 3 elbow arthrodesis at 90° elbow flexion secured with a plate and screws. All 3 patients experienced fracture at the most distal aspect of the posterior plate, consistent with a stress riser in this location.

CONCLUSION

The risk of fracture is likely related to vulnerability of the arm with no elbow flexion and may not be ameliorated by changes in operative technique or bone quality. Ulna fracture can be anticipated after elbow arthrodesis and might further limit enthusiasm for elbow arthrodesis.

Complex open elbow fracture Gustilo-Anderson type IIIB treated with the primary elbow arthroplasty: A case report

Total elbow arthroplasty as a treatment option for open elbow fracture is relatively rare described. We reported a 39 years old polytrauma patient with complex open elbow fracture (Gustilo-Anderson type IIIB). The patient presented with large soft tissues defect on dorsal part of the left elbow, ulnar palsy due to the irreparable loss of the ulnar nerve, distal triceps loss due to the complete loss of the olecranon, loss of both humeral condyles with collateral ligaments and complex elbow instability. Only few similar cases have been published. Reconstructive surgery included repetitive radical debridement, irrigation, vacuum assisted closure system therapy, external fixation, coverage of the soft tissue defect with fascia-cutaneous flap from the forearm. Four months after the injury, total elbow arthroplasty with autologous bone graft (from the proximal radius) inserted in the ulnar component, was performed. At 3 years postoperatively, the patient is able to perform an active flexion from 0° to 110° with full prono-supination. Only passive extension is allowed. The ulnar neuropathy is persistent. Patient has no signs of infection or loosening of the prosthesis.

Elbow Fracture-Dislocations: Determining Treatment Strategies

Elbow dislocations represent common injuries. A quarter of these injuries involve at least 1 fracture. The sequel of elbow fracture-dislocations can be fraught with complications, including recurrent instability, posttraumatic arthritis, elbow contracture, and poor functional results. The 3 main patterns of injury are valgus posterolateral rotatory instability, varus posteromedial rotatory instability, and transolecranon fracture-dislocation. This article discusses each pattern individually, including the anatomy, the typical injury pattern, and treatment strategies. It also discusses common complications that can occur.

Complex Case of Open Fracture-Dislocation of the Elbow

Complex elbow instability is difficult to surgically address. Careful consideration of the fractures and soft tissue injuries is required. We present the case of a patient who sustained an open fracture-dislocation of the elbow with significant loss of the external humeral condyle and partial loss of the olecranon. He was surgically treated with an iliac crest tricortical autograft fixed with a buttress plate and a lag screw. His lateral ulnar collateral ligament was reconstructed with tendinous autograft collected from his third and fourth extensor digitorum longus tendons. While the procedure complicated with a Nocardia infection and wound breakdown, the patient almost had full range of motion without instability at 11 months of follow-up.

Vascularized Composite Allotransplantation of the Elbow Joint: A Cadaveric Study

BACKGROUND

Surgical options for the unreconstructable elbow are limited to arthrodesis, total arthroplasty, or osteoarticular allograft reconstruction. Each of these options is limited by severe functional impairment and/or high complication rates. Vascularized allotransplantation of the elbow joint has the potential to mitigate these complications. In this study, we describe our technique for harvesting the elbow for vascularized joint transplantation and demonstrate the flap's vascularity using contrast angiography.

METHODS

Anatomical studies were used to design and harvest a vascularized elbow joint flap pedicled on the brachial vessels in 10 cadaveric arms. Diaphyseal blood supply is provided by 3 nutrient arteries, and periarticular supply arises from the various collateral arteries of the arm and recurrent arteries of the forearm. The brachialis and supinator, and their respective nerves, were included as functional muscles because of their intimate association with critical vasculature. Tendinous insertions of the biceps and triceps, as well as the flexor/pronator and extensor origins, were preserved for repair in the transplant recipient. Both lateral arm and radial forearm flaps were preserved to aid in soft tissue inset as well as vascular/immunologic monitoring. Contrast angiography of each dissected specimen was performed to assess the location of the nutrient vessels and assess flap vascularity, as indicated by filling of the critical extraosseous and endosteal vessels.

RESULTS

Angiographic imaging of 10 specimens demonstrated that this flap dissection preserves the nutrient endosteal supply to the humeral, radial, and ulnar diaphysis, in addition to the critical extraosseous arterial structures perfusing the elbow joint and periarticular tissues. From proximal to distal, these arteries are the musculoperiosteal radial, posterior branch of the radial collateral, inferior ulnar collateral, recurrent interosseous, radial recurrent, and the anterior and the posterior ulnar recurrent.

CONCLUSIONS

Vascularized composite allotransplantation of the elbow joint holds promise as a motion and function preserving option for young, high-demand patients with a sensate and functional hand, who would otherwise be limited by the restrictions of total elbow arthroplasty or fusion. In this study, we propose a flap design and technique for harvest and also offered vascular imaging-based evidence that this flap is adequately vascularized.

Elbow vascularized composite allotransplantation-surgical anatomy and technique

BACKGROUND

Elbow reconstruction with vascularized composite allotransplantation (VCA) may hold promise in treating end-stage arthritis as no current treatment is both functional and durable. We describe the vascular and gross anatomy of the elbow in the context of VCA procurement and propose a step-by-step surgical technique for human elbow VCA.

METHODS

We injected latex in the arterial tree of 16 fresh adult cadaveric upper extremities. We identified and measured arteries and nerves and their branch points relative to the medial epicondyle. Based on our determination of the dominant blood supply to osseous and capsular elbow structures, we derived a cadaveric model of elbow VCA by performing donor preparation on 2 fresh cadaveric upper extremities by elevating a lateral arm flap in conjunction with the vascularized elbow joint. We prepared and transplanted 2 size-matched recipient specimens to refine the surgical technique.

RESULTS

The elbow arterial supply was composed of consistent branches contributing to medial, lateral, and posterior arcades. Preservation of the elbow arterial network requires sectioning of the brachial, radial, and ulnar arteries 12 cm proximal, 1 cm distal, and 6 cm distal to the ulnar artery takeoff, respectively. The supinator, anconeus, distal brachialis, proximal aspects of the flexor digitorum profundus, and flexor carpi ulnaris must be preserved to protect osseous perforators. Articular innervation was most commonly derived from ulnar and median nerve branches. We refined our proposed surgical technique after performing 2 cadaveric elbow VCAs.

CONCLUSIONS

Elbow VCA may be technically feasible on the basis of its consistent vascular anatomy and our proposed surgical technique.

Neuropathic arthropathy of the elbow treated with double-plate arthrodesis and resection site bone graft

Neuropathic arthropathy of the elbow is a rare condition, which is disabling and difficult to treat. Initial treatment is conservative and arthrodesis is rarely indicated. We describe an unusual case of progressive unilateral elbow swelling in a 37-year-old female domestic helper. She was found to have neuropathic arthropathy of her right elbow secondary to underlying cervico-thoracic syringomyelia. She underwent decompression of the syringomyelia before underdoing elbow fusion. Her elbow was initially immobilized in a cast to minimize bony fragmentation and soft tissue swelling. Serial X-rays were performed with a regular change of cast as the swelling subsided. When there was no further radiological evidence of bony fragmentation, elbow fusion at 60° was performed using a two-plate technique at 7 months after the initial presentation. With well-preserved ipsilateral hand function, she was could still perform household chores despite having a fused elbow. Radiological evidence of successful elbow fusion was documented at 23 weeks after surgery. There were no complications. If elbow fusion is considered, we recommend a trial of immobilization in the preferred angle of fusion to assess the patient's suitability. Factors such as the young age of a patient and good quality bone may also contribute to the success of the fusion.

Elbow arthrodesis for post-traumatic sequelae: surgical tactics using the Ilizarov frame

BACKGROUND

Surgical arthrodesis of the elbow joint is frequently unsuccessful and rarely performed. It is the purpose of this article to evaluate tactics and different constructs to achieve elbow arthrodesis (EA) using the Ilizarov apparatus in patients with post-traumatic nonreconstructable elbow sequelae.

METHODS

A consecutive series of 4 patients were treated between 2009 and 2013 (3 men and 1 woman; mean age, 46.7 [35-75] years). Two patients had late complications in total elbow replacement and developed nonunion after condylar fractures of the distal humerus. There were 3 ulnohumeral arthrodeses and 1 radiohumeral arthrodesis. The hybrid advanced Ilizarov technique was used in all cases.

RESULTS

Complete union was obtained in 3 EAs (75%) without additional surgery at an average of 23 weeks. Fusion angles ranged from 90° to 120°. One patient required amputation above the elbow because of persistent infection and chronic pain after attempted reconstruction with distraction osteogenesis for infected total elbow replacement with humeral bone loss. The average length of follow-up after EA was 33 months (range, 18-60 months). At final follow-up, the median score of the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire was 42.4 (27.3-52.2). Three patients returned to their working activities.

CONCLUSIONS

EA is not a common orthopedic procedure. Despite its difficulties and need of specific training, the Ilizarov technique provides a reproducible and reliable way of achieving solid fusion with the desired angle. Advantages include infection control, early mobilization, accurate application, convertibility and versatility compared with a monolateral fixator, and improved union rate.

Elbow arthrodesis: a novel technique and review of the literature

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.