MILITARY MEDICINE. 170. 2:164. 2005

Elbow Arthrodesis after War Injuries

Guarantor: Ranko Bilic. MD PhDContributors: Ranko Bilic. MD PhD: Roberl Kolundzic. MD: Goran Bicanic. MD: Kresimir Korzinek. MD PhD

Arthrodesis is a surgical procedure that results in fusion ofthe joint and hony ankylosis. With this operation, we canachieve satisfactory function of the limh in cases in whichoptions for different treatments no longer exist. Severe jointdestruction, joint infections, and nonunions, as well as com-plex war injuries (with large bone and soft tissue defects), areindications for arthrodesis. The elhow is the most susceptiblejoint of the upper limb to war injury. Between 1992 and 1995.we perfonned elbow arthrodesis for nine patients in our de-partment after war injuries. As analysis ofour results shows,elbow arthrodesis, although a rarely performed surgical pro-cedure, is the best treatment for patients with complex warinjuries of the elbow. For arthrodesis, we used extemal fixa-tion in combination with intemal fixation (cancellous bonescrew) and additional autologous cancellous bone grafts.

Introduction

E lbow arthrodesis is a rare surgical procedure that results inbony ankylosis (bony overgrowth of the joint). Sa(isfac!or\'

upper limb tunction can be achieved for patients with painfuland minimally mobile elbows or patients with large defects oftheelbow joint.' Extra-artieular and intra-articular techniques, aswell as combinations of those techniques, have been describedin the literature.'"" Extra-articular techniques have been usedonly with Iarge chronic elbow defects.''''" The descriptions ofearlier teehniques ineluded local and free bone transplants withonly 50% bony ank\'losis of the elbow,- Along with improve-ments in extemal and intemal fixation, new teehniques forintra-articular elbow arthrodesis were developed.̂ '̂ Methodsthat are now used include extemal fixation alone or in combi-nation with intemal fixation (with caneellous bone screws orcompression serews) or solely intemal fixation with a plate (withor withoul compression screws).'' The results of these teeh-niques proved to be much better (between 50% and 100% bonyankylosis) and healing times much shorter."* ^ '̂ '•'' Mueller et al.^deseribed an intra-articular technique for elbow arthrodesiswith reseetion of ali three elbow joint surfaces (humenis. ulna,and radius) and a combination of extemal and intemal fixation(eompressive osteosynthesis with exlemal PLxation and an axialcancellous bone screw with washer). The war in the Republic ofCroatia eaused an increase in the number of elbow injuries. Weused the Mueller technique for elbow arthrodesis. combinedwith autologous cancellous bone grafts (from the iliac bone),when large bone defects were present. In this article, we presentthis modified procedure and the results after surgery.

Dfparlmom of Onliopaedic Surgery-. Clinical Hospiiai Centre Zagreb. School ofMedirine, University ol Zagreb. Salata" 7. 10000 Zagreb. CroaUa.

This manuscript was received for review In June 2003. The revised manuscript wasaccepted ibr publication in March 2004.

Reprint & Copyright ® by Association of Militaiy Surgeons of U.S.. 2005.

Methods

Patients and Assessments

The study was a records review study, in which we analyzedthe results after elbow arthrodesis for patients treated in theDepartment of Orthopaedic Surgery, School of Medicine. Uni-versity of Zagreb. Patients were initially treated at the injury site(mostly first lines of fire), where primarv' wound treatment andtemporary immobilization with a CMC extemal fixator'"' wereperfomied. All patients were treated for war-related elbow inju-ries. Indications for the operation were complex comminutedfractures and nonunions after primary immobilization. Postop-erative X-rays were taken, and bone fusion was observed. Afterthe records review, all patients were invited for a clinical exam-ination. Control X-rays were taken during the examination, andpatient satisfaction and functioning in ever̂ t'day activities wereevaluated. For patient satisfaction, the following gradation wasused: vew satisfied, satisfied, or unsatisfied. For functioning ineveryday activities, the following gradation was used: no restric-tion, mild restrietion. severe restriction, or incapable. No restric-tion or mild restrietion was considered a good result, severerestrietion was eonsidered a satisfactory result, and incapable ofeveryday activities was considered a poor result. For pain eval-uation, a visual analog scale was used (0 points, no pain: 10points, worst pain ever).

Operative Technique

A toumiquet is used for the surgical procedure. We use aposterior approaeh for the elbow exposure. After exposure, re-section of the distal humems and olecranon is perfomied. fol-lowed by reseetion of the head of the radius just above theinsertion ofthe biceps muscle. After remodeling ofthe resectedsurfaces, two Schanz screws are drilled into the humems andtwo into the ulna. The proximal humeral Schanz screw is con-nected to the distal ulnar Schanz screw uith one bar. and thedistal humeral screw and the proximal ulnar screw are eon-neeted with another bar. The bars are then connected together,for better fixation of the whole constmction (Fig. 1). After exter-nal fixation is completed, intemal fixation with a cancellousbone screw and washer is applied [Fig. 2). Before final tighteningofthe screw and final compression between the Schanz screws,autologous cancellous bone from the iliac bone is inserted be-tween and around the resected surfaces. Postoperative treat-ment is based on finger exercises, which start on the first day.and shoulder luid wrist exercises, which stari on the third post-operative day.

Results

A total of nine patients were surgically treated. There wereeight men and one woman, with a mean age of 29,7 years (range.22-40 years). Indications for the operation were complex com-

Militar̂ • Medicine. Vol. 170. February' 2005 164

Elbow Arthrodesis 165

Fig. I. External Hxation device.

Fig. 2, X-rays ublaiiicd immediately after elbow arthrodesis. with combinedextemal and intemal fixation (left, anteroposterlor projection: right, left lateralprojection).

minuted fraetures for four patients and nonunions for five pa-tients. The operation was pertbrmed an average of 8.5 monthsafter the primary war injury (range. 3 weeks to 37 months).Follow-up periods were 8 to 11 years.

The wounds were primarily infected for three patients (twopaiients with Pseudomonas and Profeus and one patient withAcinetobacter sp.]. but infections were treated hefore the elbowarthrodesis. Temporar}' fixation with a CMC fixator was per-formed for six patients. Extemal fixation in eombination withcancellous bone screws was used in seven cases, and extemalfixation alone was used in two cases. The median elbow jointposition was 90 degrees of flexion (average, 88 degrees; range.60-100 degrees). X-ray analyses showed that the shortest pe-riod necessary for fusion of the elbow (bony anlq'losis) was 5

months and the longest was 7.5 months. The average timeneeessary for fusion (bony ankylosis) after elbow arthrodesiswas 6 months 10 days (Fig. 3). The extemal fixator was left inplace an average of 12.5 months (range, 9-15 months). Revisionoperations were performed in two eases: we perfonned rearth-rodesis in one case (because of nonunion after arthrodesis) andrefixation with new Schanz screws in the other (because ofloosening ofthe originally placed Schanz screws). In the secondcase, repositioning of the uinar nerve was also perfonned be-cause of the cubital tunnel syndrome (ulnar nenT compressionwas seen). Long-term follow-up monitoring (8-11 years) showedno complications (no loosening and no irifections). All patientswere very satisfied or satisfied with the results, and eight of ninepatients had good results regarding everyday activities. For onepatient, satisfactory results regarding everyday activities wereachieved.

Discussion

War-related elbow injuries, because oftheir complexity (largebone defects, large soft tissue defects, and wound contamina-tions) and because mainly younger populations are affected,demand fast definitive treatment. For these large, open, intra-articular fractures (after trauma or wounding) associated withexcessive bone and soft tissue loss, elbow arthrodesis is amethod of choice (Fig. 4). During the decision-making processregarding elbow arthrodesis, one must take into account medi-cal and occupational indications, the age ofthe patient, and thecondition of nearby joints that will partially take over the func-tion of the elbow. Candidates for elbow arthrodesis are youngerpatients witb greater need for strength and stability of thearm.^'^ Arthrodesis is commonly used in cases in wbich theelbow is painfui and minimally mobile or in whicb complicationsor failure of other surgical procedures' is expected.

Elbow arthrodesis is also a metbod of choice for the treatmentof complications of septic or tuberculous arthritis when exten-sive destmction of joint surfaces occurs.'*"' Post-traumatic el-

Fig. 3. X-rays obtained 2 years after elbow arthrodesis, showing total bonyovergrowth in 90 degrees of flexion. The cancelious bone screw is not removed,because of possible extensive bone destruction during removal and weakening ofthe arthrodesis (left, anteroposterior projection; right, left lateral projection).

Military Medicine. Vol. 170. February 2005

166 Elbow Artbrodesis

Fig. 4. X-rays for a 23-year-oid. Croatian Army soldier, showing significant elbowdestruction with a humeral diaphyseal fracture and soft tissue defect (woundedwith a high-kinetic energy projectile) (left, anteroposterior projection: right, leftlateral projection).

bow arthrosis and failed elbow arthroplasty are also indicationsfor elbow artbrodesis."'''' Every operative procedure, includingelbow arthrodesis. has contraindications. Relative contraindica-tions are reduced mobility of tbe ipsilateral shoulder, wrist, orcervical spine. For patients for whom both elbow joints areinvolved, alloartbroplasty or resection arthroplasty of at leastone elbow is preferred,- '•'̂ •"'Tbe optimal elbowjoint position forartbrodesis varies; it depends mostly on specific functional de-mands, the patient's occupation, and compensatory arm andneck movement ability. Most authors suggest 90 degrees offlexion as the best position for elbow arthrodesis on the domi-nant side, with normal sboulder. wTist. and spine mobility. Thisis tbe best position for activities of everyday living (writing,eating, and personal hygiene) and allows maximal armstrength.'•^•*'^'''''Arthrodesis with 45 to 60 degrees of flexion issometimes better (for some professions) and provides a bettercosmetic appearance.-i'^ Tbe best position ofthe forearm for thearthrodesis, in cases in wbicb rotation is not possible, is aneutral position, slight pronation (for better wrtting ability andbetter ability to use a compuler). or sligbt supination (for betterobject-holding ability).''' For both-side elbow arthrodesis. 90degrees of flexion on one side and 45 to 60 degrees of flexion onthe other side is proposed.- '̂ II is advisable to immobilize thepatient's elbow in the desired position before tbe operation, forbetter evaluation of the patient's preferences.'* '̂̂

Conclusions

Elbow arthrodesis is the definitive treatment for complex.open, intra-articular fractures witb bone and soft tissue lossafter wounding or large traumatic defeats. Tbe best position forelbow arthrodesis is 90 degrees of flexion, wbich ensures easyfunctioning in activities of everyday living and personal hygienemaintenance. Our results show that extemal fixation, alongwith intemal fixation witb cancellous bone screws and washerscombined with autologous cancellous bone grafts, is an effectivemethod for achieving arthrodesis of tbe war-injured elbow. Pa-tients should be cautioned, bowever, that prolonged immobili-zation witb an extemal fixator is required.

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Military Medicine. Vol. 170. February 2005