Review Question - QID 219811

Elbow Arthritis Treatment Operative QID: 219811 (SBQ24SE.19)

QID 219811 (Type "219811" in App Search)

A surgeon performs an elbow procedure where the distal humeral and proximal ulnar subchondral bone is prepared with a high-speed burr until they are congruent. He then lays an Achilles tendon allograft over the end of the distal humerus and anchors it with a braided suture as shown in Figure A. Ligamentous repair is performed and backed up with a hinged elbow external fixator. Which of the following patients is this procedure the best candidate for?

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65-year-old woman with rheumatoid arthritis of the elbow

10%

58/598

26-year-old man with recurrent septic elbow arthritis leading to distal humerus osteomyelitis

14/598

20-year-old man with severe posttraumatic elbow arthritis after a remote intraarticular distal humerus fracture

62%

373/598

85-year-old man with a distal humeral valgus malunion after an intraarticular distal humerus fracture

42/598

45-year-old woman with chronic elbow instability after posterolateral elbow dislocation

18%

107/598

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The procedure described is elbow interposition arthroplasty. Young patients with severe posttraumatic arthritis after a distal humerus fracture are good candidates for interposition arthroplasty after failing conservative management of arthritis.

Elbow interposition arthroplasty is a style of resection arthroplasty that involves restoration of the distal humeral and proximal ulnar geometry, debridement of osteophytes, and interposition of a dermal, fascial, or tendinous graft in the joint. The addition of a distracting hinged elbow external fixator can be considered to offload the graft, allow for early range of motion, and protect ligamentous repairs. One of the theoretical advantages of elbow interposition arthroplasty is the ability to convert to total elbow arthroplasty in the future.

Elbow interposition arthroplasty is indicated in young patients with elbow arthritis who otherwise are not candidates for prosthetic replacement due to lifting restrictions and age. Relative contraindications to interposition arthroplasty include elderly patients over 60 years of age who are candidates for total elbow replacement. Absolute contraindications to interposition arthroplasty include active infection and chronic instability without adequate bone stock for ligamentous reconstruction.

Morrey et al. review the current indications, techniques, and outcomes of elbow interposition arthroplasty. They perform a posterior triceps sparing approach and utilize an Achilles allograft as the interposition graft. A hinged elbow external fixator is applied to protect the ligamentous repair postoperatively and allow for early range of motion. They conclude that elbow interposition arthroplasty is a reasonable option for young patients who are not candidates for total elbow arthroplasty.

Larson et al. present a case series of 38 patients undergoing interposition arthroplasty with Achilles tendon allograft. Their results were mixed, with thirteen patients achieving a good or excellent result, fourteen with a fair result, and eleven with a poor result; the remaining seven underwent revision. There was an overall improvement in the average MEPS score postoperatively. They conclude that interposition arthroplasty is a reasonable interim salvage procedure for young patients to bridge to a future prosthetic replacement.

Figure A is an intraoperative radiograph of an Achilles tendon allograft overlying the distal humeral articular surface, which has been prepared with a burr.

Incorrect Answers:
Answer 1: This patient would best be suited for total elbow arthroplasty.
Answer 2: Active infection is a contraindication for interposition arthroplasty.
Answer 4: This patient would best be suited for total elbow arthroplasty.
Answer 5: Chronic elbow instability is a contraindication for interposition arthroplasty.