Last Updated on August 12, 2023
Elbow arthrodesis refers to the surgical fusion of the elbow joint. It is not a commonly performed procedure in modern times.
Historically, infection, mainly tuberculosis leading to a painful ankylosed elbow has been the main indication for performing elbow arthrodesis. But with modern chemotherapy, socioeconomic development has led to the reduction of tuberculosis drastically.
Nowadays, surgical fusion of the elbow is a salvage procedure only.
The procedure aims to fuse the elbow to produce a painless and stable elbow in a functional position. The position of the elbow varies depending on the demands/profession of the patient and other factors like the condition of the other elbow, shoulder, and spine.
The outcomes of the procedure are variable and complications may occur.
Indications of Elbow Arthrodesis
Elbow arthrodesis is often a last resort procedure in modern times because the loss of motion significantly affects the quality of life of the patient.
Total elbow arthroplasty is a more commonly done procedure as it provides a mobile elbow. So in a nutshell, elbow arthrodesis is considered only in cases of failed arthroplasties and in patients where arthroplasties are contraindicated.
Elbow arthrodesis can be considered in the following situations
- Intractable painful and unstable elbow
- Elbow joint destruction due to infection or trauma where arthroplasty is not suitable/contraindicated
- Trauma resulting in severe comminution
- Gunshot injury
- Motor vehicle accidents
- Industrial accidents
- Large bone and soft tissue defects
- Infection
- Tuberculosis
- Bacterial Infection
- Trauma resulting in severe comminution
- Severe rheumatoid arthritis
- Poor bone quality
- Young laborers with debilitating arthritis who require a strong and stable joint as arthroplasty fails under repetitive loading
Contraindications
Dysfunction or disease of the shoulder and/or upper spine is the contraindication of this procedure.
After arthrodesis of the elbow compensatory movements are provided by the upper thoracic spine and shoulder joint including the scapulothoracic joint. If there is a dysfunction of these joints, compensatory motion is not provided.
Position for Elbow Arthrodesis
The elbow is fixed in varying degrees of flexion depending on many factors including the needs and demands of the patient.
There is no angle of fusion that is suitable for all activities. Hence, it requires diligent work on both physician’s and patient’s part to reach the profile that best matches the expectation.
- In the case of unilateral fusion, the most recommended position is 90 degrees of flexion. The elbow is fixed in neutral rotation.
- In bilateral fusion, the angle of the fusion is 110-120 degrees in the dominant and less than 90 [45-60] degrees in the non-dominant. This allows the hands to reach the whole body for personal hygiene and a daily range of work.
The following factors must also be considered for achieving a conclusion-
- Patient’s age
- Occupation
- The dominant or nondominant hand
- Needs and requirements of the patient
- Rotation
- Slight pronation provides a better ability to write and use computer
- Slight supination is better for object-holding
The choice of fusion angle must be individualized to meet each patient’s specific needs. It is highly recommended to simulate fusion via functional bracing at different angles prior to the procedure.
Image Credit: SAGE
Surgical Procedure
Preparation for Surgery
The wounds should heal before the procedure is taken up or planned. Extensive infection/discharge needs to be controlled by debridement, dressing, and antibiotics.
The patient should spend a lot of time in preoperative simulation by immobilizing the elbow using a functional brace. This will let the patient and physician know if the patient is ready for elbow arthrodesis or not. Also, it helps to determine the suitable position of the elbow it needs to be fused in.
Surgical Procedure Outline
- Exposure
- Most surgeons use a posterior approach
- Tissues like ligaments, joint capsules, and synovium are removed and bone surfaces are exposed
- Debridement of the remaining articular surface and sclerotic bone till the healthy bleeding bone is reached
- The ulnar nerve should always be identified and protected because it is vulnerable during the majority of these cases as the posterior approach to the elbow is used. Depending on the amount of bone resected and the position of hardware placement, ulnar nerve transposition may be required.
- Fixation
- Internal fixation is usually preferred as it provides rigid compression across the arthrodesis site
- Implants
- Posterior plating is the preferred method
- Compression screws
- External fixators
- Various combinations of the above
- Bone grafting
- Fills the gap. if any between compressed surfaces
- Hastens union and reduces the risk of nounion
Complications
- Infection
- Persistent nerve pain (neuroma)
- Failure of implant like loosening or breakage
- Breakdown of skin or scar
- Refracture
Conclusion
The goal of elbow arthrodesis is to produce a painless, immobile elbow. Therefore,, the procedure needs to be justified and used as a last resort only. The patient should definitely undergo preoperative simulation as to how would arthrodesis affect the quality of life and what is the best position for fusion in his case.
When carefully and diligently selected, the procedure yielded good results and allowed the patients to go back to work.
A successful procedure is one that leads to patient satisfaction and keeps her pain-free.
References
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Reichel LM, Wiater BP, Friedrich J, Hanel DP. Arthrodesis of the elbow. Hand Clin. 2011 May;27(2):179-86, vi. doi: 10.1016/j.hcl.2011.02.002.
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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.
- Kwon YW, Morrey BF. Neuropathic elbow arthropathy: a review of six cases. J Shoulder Elbow Surg 2006;15:378-82
- Kovack TJ, Jacob PB, Mighell MA. Elbow arthrodesis: a novel technique and review of the literature. Orthopedics. 2014; 37(5):313–319. 10.3928/01477447-20140430-04
