Radiohumeral arthrodesis with external fixation. A minimally invasive procedure
for failed revision joint replacement of the elbow.
Francesco Sala1, Carlo Bonifacini2, Nicolò Martinelli2, Rosario Spagnolo3, Dario Capitani1
1Department of Orthopaedic Surgery and Traumatology, Niguarda Hospital, Milan, Italy.
2Department of Ankle anf Foot Surgery, Galeazzi Hospital, Milan, Italy.
3Surgery Free Land, Treviglio Hospital, Milan, Italy.
Corresponding author: Francesco Sala, MD. Paolo Giovio 45, Milan 20144, Italy; E-mail: firstname.lastname@example.org
Citation: Sala F, Bonifacini C, Martinelli N, Spagnolo R, Capitani D. Radiohumeral arthrodesis with external fixation. A minimally invasive procedure for failed revision joint replacement of the elbow. J Minim Invasive Orthop, 2014, 1(3): e3. doi:10.15383/jmio.3.
Competing interests: The authors have declared that no competing interests exist.
Conflict of interest: None
Copyright: 2014 By the Editorial Department of Journal of Minimally Invasive Orthopedics. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Elbow arthrodesis (EA) is a rare procedure to be performed and it is still considered a salvage approach to be chosen in selective cases only5,9,10 . As reported by Koller it is one of the most difficult arthrodesis to perform for the surgeon with a high impact on the patients’ quality of life7. This procedure is even more challenging when a massive bony defect occurs as it is the case after removal of a failed total elbow arthroplasty4. Traditional EA is performed between the humerus and the ulna, due to the larger surface areas available, as reported by Staples, who described the employment of an olecranon wedge against the humerus16, or by Müller and Song, who suggested a plate compression between those two bones7, 15 . The hypothesis whether a radiohumeral arthrodesis should be performed when the proximal ulna is completely absent due to reabsorption is based on anectodal evidence and few alternatives, as vascularized bone grafting, or renewed arthroplasty are available to the surgeon6,9 . We present a case report of a 75 year old woman who had a history of multiple total elbow replacement failures with a massive ulnar bone loss in which a radiohumeral arthrodesis with external fixation was performed. Complete fusion was obtained with more than satisfactory results on the patient’s quality of life.
Keywords: Elbow arthroplasty; radiohumeral arthrodesis; external fixation; minimally invasive procedure; arthroplasty failure; physical function
A 75 year old, right-handed woman was referred to the outpatient clinic with symptoms of disabling pain on her right elbow with signs of ulnar nerve involvement and with a series of previously failed elbow arthroplasties. Hypertension, type 2 diabetes mellitus chronic vertigo, and metabolic syndrome were the referred comorbidities. In March 2001, she sustained a terrible triad injury with a posterior dislocation of the elbow, associated with radial head and coronoid process fractures, which was treated in two steps by osteosynthesis failure of the radial head, and subsequent radial head resection with temporary stabilization of the ulnohumeral joint; consequently a total elbow arthroplasty it was performed due to severe pain and instability of the joint six months later (Fig. 1). After two years of relative well being from the first surgery, she developed a painful elbow and radiographic evidence of periprosthetic loosening with radiolucent lines, and focal osteolysis around prosthese were noted (Fig. 2a). In 2003, revision surgery was planned. High implant stability was granted by additional plate fixation of the construct with autologous bone graft to fill the defects (Fig. 2b). New signs of aseptic loosening were highlighted in 2010 (Fig. 2c). Routine blood tests showed normal values of inflammation markers. Removal of prostheses and temporary external fixation of the joint augmented with autologous bone graft and antibiotic beads were performed in July 2011. (Fig. 2d). Nevertheless multiple microbiological cultures were negative. In october 2011 a new elbow prosthesis was implanted with the aid of a fibular allograft to reconstruct the proximal ulna (Fig. 2e), which failed in march 2012, because of a stress fracture occurred in the middle of the grafted fibula. (Fig. 2f). In june 2012 complete debridement and removal of the prosthesis through a dorsal approach was performed and a radiohumeral arthrodesis through a hybrid external fixator was performed (Fig. 3). Particular attention was paid to resect the humeral and radial surfaces to raw, bleeding cancellous bone and to press the iliac crest graft underneath the distal humerus. The elbow was stabilized in frame with an angle of 100°, with an intermediate foream rotation. In january 2013 the external fixator was removed. At one year of follow up, in january 2014, signs of complete radiographic fusion were observed with minimal residual pain and high satisfaction of the patient (Fig. 4). Postoperative care included management of the pin site according to the Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics and weight carriage avoidance until signs of radiographic consolidation were present3.
The evaluation of Personal Care and Hygiene tasks and the evaluation of Activities of Daily Living showed limitations not dissimilar to those obtained in healthy subjects with simulated EA which were 11 and 12, respectively. The MAYO performance elbow score (MEPS ) that consists in the assessment of pain, arc of motion, stability, and function of the elbow joint was 75 points (good) on a scale with a maximum of 100 points13,14. Actually, the patient feels satisfied despite the objective perceived limitations.
Written informed consent was obtained for publication of this case report and relative accompanying images.
Figure 1. Terrible triad injury. Elbow dislocation with fracture of the radial head (a), treated with open reduction and internal fixation (b); failure of the synthesis treated with radial head resection and ulnohumeral transfixation with excision of the fracture's fragments (c, d); elbow arthroplasty performed for instability with severe pain (e).
Figure 2. Periprosthetic loosening of the first implant (a); first revision surgery with bone graft and plate fixation (b); signs of aseptic loosening of the implant (c); temporary external fixation with autologous bone graft and antibiotic beads (d); revision arthroplasty with homologous fibular graft and plate (e); loosening and implant mobilisation (f).
Figure 3. Open approach (a) for implant removal and debridment; radiohumeral arthrodesis achieved with hybrid external fixator ; anteroposterior and lateral view radiographs (b,c).
Figure 4. Lateral and anteroposterior view radiographs show the limb at 6 months after frame removal (a,b). , Front view of the upper limb shows stable arthrodesis and the absence of deformity (c,d).
Elbow arthrodesis is nowadays a seldom performed salvage procedure, which should be reserved to cases where no feasible reconstruction can be warranted2,9-11, 17 . The once common indication for an elbow fusion in the presence of a Pott’s disease of the elbow has been limited due to the increased effectiveness of the medical treatment available1 ; the same limitations in its performance are appreciated in the treatment of severe war related injuries at the elbow joint thanks to improved reconstructive strategies2 . Many surgical techniques, which date back at the time of tubercular arthritis, are described in the literature, but most of them have the prerequisite of an intact bone stock at the elbow joint1,6 . Kälicke reported that an arthrodesis might only be performed when enough bony substance is available at the elbow and that other procedures, like allograft reconstruction, should be otherwise preferred5 . Even though this assumption, it may sound obvious the question of how much residual bone is enough to grant a successful outcome. This case reported is characterized by a massive loss of ulnar bone and a minor loss of the radial head due to initial capitellectomy performed as primary approach to first traumatic event. Type II dyabetes previous failure of allograft implant and multiple arthroplasties failures limited our surgical choice. In fact, the choice for the best available procedure was influenced by the concerns of an undiagnosed deep tissue infection of the arthrodesis. External fixation has shown advantages over internal fixation in such scenario by avoiding the use of fixation directly into the infected area 18,19 The traditional Ilizarov approach provides simple compression of the osteotomy surfaces and this is eventually associated with periods of distraction to stimulate osteogenesis. 20 A further major advantage of external fixation is less soft tissue disruption with faster wound healing, which had to be considered in our diabetic and vasculopathic patient. Vascularized fibular graft was not considered for the presence of these comorbidities.
Therefore , we decided to perform a radiohumeral arthrodesis with external fixation for failed elbow arthroplasty, that nowadays was not yet reported in literature. Radiohumeral arthrodesis has been described only in a few cases in the literature by Presnal who used internal plate fixation as their treatment of choice and by Kato, who performed radiohumeral arthrodesis in an open comminuted fracture in the EA setting without bone grafting9,6 . Both papers underlined ulnohumeral arthrodesis as the standard is the standard technique for elbow fusion due to the geometry and larger surface of the ulna respect to the radius and due to the possibility of maintaining supination and pronation of the forearm. The impairment of losing the residual forearm rotation, which consisted of less than 5°, was discussed with the patient who considered it as a minor concern. The patient desired to become painless with a further wish of a definitive procedure. Therefore, radiohumeral arthrodesis was considered a feasible technique in this case. A further concern of EA is the optimal fusion angle which is partly debated and it changes depending on patient’s characteristics. As suggested by Tang et al. the best position for fixation must consider multiple variables, like the patient’s age and occupation, and ultimately by patient’s preference17 . A common decision of a target range between 90° and 100° was chosen by our patient after different preoperative simulations. The procedure was performed under general anesthesia and, even if there are numerous approaches available to the elbow joint, a long, longitudinal, posterior incision was preferred in our case to guarantee a sufficient debridement of the residual joint and the correct preparation of the humeral and radial surfaces. We believe that some technical details contributed to the success of the subsequent compression. First, the debridement during the initial surgery was very thorough, extending to viable, bleeding bone on both sides, but avoiding any periosteal stripping of the bone ends. In addition, the bony resection was made in a plane strictly perpendicular to the long axis of the radio, taking great care to perfectly align the bone ends during compression. It is clearly reported in literature that success of such procedures depends greatly on these factors.
Aseptic loosening of elbow arthroplasty is often associated with bone loss. When this loss involves the ulna, an elbow arthrodesis may be a demanding procedure with a high incidence of complications and resulting in significant functional disability. The best position of elbow arthrodesis remains unclear. We have successfully treated a total elbow arthroplasty failure with significant bone loss of the ulna through a radiohumeral arthrodesis performed with an external fixation. This is a minimally invasive procedure of last resort and it should only be performed when no other options for limb salvage exist.
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