Arthroplasty of the Elbow

The mobilization of an ankylosed elbow may be accomplished by simple excision, provided sufficient bone is removed, but such a procedure may render the part weak and unstable. To reconstruct a joint, with a wide range of motion and stability, which will stand the strain of average daily use, is a far more difficult problem. However, unless such a result can be secured a stiff joint in the most use-ful position is preferable.

In only selected cases should operative procedures for mobilization of an ankylosed joint be considered. The following pathological conditions, which are encountered, decrease the chances of success or actually contraindicate surgical measures:

There are, in reality, only two conditions in which open surgical procedures should be employed in ankylosed joints for the purpose of restoring motion: First, traumatism, causing a crushing of the joint surfaces with tear-ing of the periosteum or multiple fractures, followed by bony ankylosis. Second, acute infectious arthritis due to staphylococcus, streptococcus, pneumococcus, gonococcus, etc. These organisms erode and disintegrate the cartilages and the superficial bone, unless the infection begins in the shaft and then we have an extensive osteomyelitis and not a localized arthritis.

In no case should this operation be lightly undertaken. The social status, occupation and coöperative intelligence, or “grit” of the patient, must be duly considered. For instance, a young woman applied for treatment with ankylosis of the elbow at about 160 degrees flexion, with the forearm in pronation. She was a pianist and in her present state able to pursue her vocation. We declined to do the operation, though good function might have been secured, but, even if such was the case, we could hardly be sure of obtaining the required degree of pronation essential to successful performance on the piano.

A chronological survey of surgical procedures for the purpose of mobilization of joints with bony ankylosis has been omitted. However, there are five well-known methods practiced at the present time by various surgeons, as follows:

Recently we have employed a sixth method in elbows, which has been satisfactory in a limited number.

Our technic was evolved from our method for the reduction of old dislocations of the elbow, in which a posterior approach is used, the triceps aponeurosis dissected free, the muscle and the periosteum incised directly down to the bone in the midline, and stripped off en masse from the lower end of the humerus. This method gave such an excellent exposure of the elbow-joint and so little damage to those structures vital to the function of the joint, that it was decided to use it as the basis for our arthroplasty operation, the details of which are as follows:

An incision is made, from six to eight inches in length, on the posterior aspect of the arm and forearm, just external to the midline, beginning above, about the middle of the humerus and ending about two or three inches below the elbow-joint. Skin, superficial and deep fascia are incised without separation, the deep fascia is dissected laterally, about one inch. This brings the broad aponeurosis of the triceps into view. This structure is dissected from above downward, making a long tongue attached to the tip of the olecranon process below. A further incision in the midline passes through the muscular fibres of the triceps and periosteum to the humerus over the lower half. A periosteal elevator is now used to strip the periosteum from the lower third of the humerus. Scar tissue, callous and loose bony particles are removed. If dislocation exists, reduction is then accomplished without difficulty with periosteal elevator, scoop, or any blunt instrument.

There is no structure of consequence in the line of incision, no danger of vessel and nerve injury if one remains close to the bone; however, if ulnar nerve is exposed it can be isolated and anchored into a position of safety. About one-half to one inch is removed from the lower extremity of the humerus, which is remodeled into a surface convex from before backward, no attempt being made to reproduce trochlea or capitellum. About one-half inch of bone is removed from the tip of the olecranon process. All scar tissue is dissected from the sigmoid cavity. With a sharp chisel the surface is removed to healthy spongy bone. The radio-ulnar articulation is not disturbed, but the surface of the head of the radius must be made the same level as the coronoid process. A rasp and file render smooth all surfaces. The periosteum and triceps muscle are dissected into a double flap, which is stitched to the anterior capsule, thus separating the raw bony surfaces by a living mass of tissue with abundant blood supply and no risk of pressure necrosis. In those cases where the radio-humeral articulation is normal with bony ankylosis between ulna and humerus, the radio-humeral joint is not destroyed, but a hemi-arthroplasty is done between the humerus and the ulna. In such cases it is not always possible to obtain sufficient posterior flap in lieu of which the aponeurotic broad tongue from the triceps is placed between the surfaces. This structure is also employed when, for any reason, the posterior flap cannot be secured. The capsule of the joint is stitched to the posterior aspect of the triceps muscle and deep fascia, thus closing off the new joint, the wound is then closed in layers with catgut and dermal for the skin.

Full flexion and extension has been secured in one case with no motion in the radio-ulnar joint, but this is well compensated by rotation in elbow and shoulder. The procedure has been employed in a limited number of cases, but sufficient to warrant description in detail. To illustrate the essential facts, two cases are briefly narrated:

The after-treatment is very important and must be under the direction of the surgeon with coöperation of a competent physiotherapeutist. However, active motion is most essential, and can only be done through the voluntary efforts of the individual. In a few elbows and other joints I have seen excellent results by voluntary efforts of the patient, without the aid of anyone, except such instructions as could be given during an office visit, though the average patient will not make the effort without the constant attendance of the gymnast.

Operations for mobilization of joints or arthroplasties are far from 100 per cent. perfect, probably more successful in the elbow than elsewhere. Young adults give the best prognosis, but this is true of all operations. Our oldest case was fifty years of age. In no case has the member been more impaired; our only permanent sequela has been a recurrence of ankylosis, but with larger experience the proportion of success is greater each year, consequently, we believe that joints with ankylosis should be mobilized by operation when feasible.