Interposition arthroplasty for post-traumatic osteoarthritis of the elbow: a systematic review

Abstract

Purpose: Interposition arthroplasty for the post-traumatic osteoarthritic elbow is a salvage procedure used in young and active patients and remains a rare and unexplored therapeutic option.

Methods: We systematically reviewed the available literature searching electronic databases, MEDLINE using the PubMed interface and EMBASE. The primary objective was to synthesize functional outcomes and to investigate revision frequencies, but also complication and subsequent surgery rates among patients with surviving grafts. The preferred reporting guidelines for systematic reviews and meta-analyses guidelines were applied.

Results: Five studies were left for inclusion, all retrospective in design, comprising 67 patients. The mean age was 40 years, the mean follow-up period was 61 months, and 68.2% of the patients treated were male. Eleven patients (16.4%) were treated with fascia lata autografts, and 56 patients (83.6%) were treated with Achilles tendon allografts. The graft survived in 53 patients (79.1%); the post-operative Mayo Elbow Performance Score averaged 69 points. Fourteen patients (20.9%) required revision surgery. In the setting of graft survival, 39.1% of patients had complications not requiring further surgical treatment and 5.7% of patients with surviving grafts needed subsequent operative treatment within the follow-up period.

Conclusion: Given graft survival, this systematic review demonstrated satisfactory functional outcomes following interposition arthroplasty of the post-traumatic osteoarthritic elbow, however, associated with a cumulative complication and subsequent operative treatment rate of 44.8%. In addition, a revision rate of 20.9% needs to be expected. Varus-valgus instability in the pre-operative clinical assessment seems to be associated with unsatisfactory post-operative elbow function. The superiority of either of the two main reported graft methods (fascia lata autograft and Achilles tendon allograft) remains pending, and the role of an external fixator in preventing post-operative instability remains unresolved.

Keywords: Elbow; Interposition arthroplasty; Osteoarthritis; Post-traumatic; Systematic review.

Fig. 1

Approach and preparation of the joint for grafting. A After sketching the bony landmarks, the skin is incised posteriorly longitudinally with lateral circumcision of the olecranon. Laterally, the Kocher interval between the anconeus and flexor carpi ulnaris muscle is established. The capsuloligamentous attachments and extensor attachments are detached humerally. B Medially, the ulnar nerve is exposed, neurolyzed, and secured. Bilateral arthrolysis follows. The medial collateral ligament (MCL) should be preserved

Fig. 2

Placement of the graft. A Three transosseous drill holes are set in a dorsoventral direction in the distal humerus: one in the area of the lateral epicondyle and one each in the area of the lateral and medial olecranon fossa. A non-absorbable suture is inserted through each of the drill holes, again in a dorsoventral direction. The ventral end of each suture is looped through the graft, followed by stitching it back through the drill holes, now in a dorsoventral direction. To ensure that the graft is properly positioned later, it is looped with two pull-through sutures at its free corners. The lateral pull-through suture is marked with a plus, the medial suture with a star. B The lateral pull-through suture is passed dorsally under the anconeus muscle (circle). C The medial pull-through suture is guided dorsomedially by means of an Overholt (circle) inserted from the ulnar side. D By pulling on the two pull-through sutures, the graft slides from ventral over the articular surfaces to the dorsal aspect of the distal humerus, illustrated by the curved arrow. The correct position of the graft is to be verified

Fig. 3

Grafts protection and reattachment of the lateral collateral ligament and the extensors. A With the three sutures pierced back through the drill holes to the dorsal side, the graft is now stitched once more from inside out. The sutures are then knotted onto the graft ensuring that it adapts to the dorsal aspect of the distal humerus (circle). B A suture anchor (circle) is inserted in the center of rotation to reattach the capsuloligamentous attachments and the extensor attachment, which have been detached humerally. The position of the interposition graft is checked again. Closure of the fascia, subcutaneous, and skin suture

Fig. 4

Study flow chart