Interposition Arthroplasty of the Elbow

Introduction

In my practice, interposition arthroplasty continues to be an essential option as salvage for end-stage arthritis of the elbow in the young patient. Selection and technique have changed little in the last 10 years. We have found no additional case series since our report.

Historical Aspects

The so-called functional arthroplasty, popularized by Hass, a variant of resection arthroplasty, might be considered the predecessor of interposition arthroplasty ( Fig. 114.1 ). Hass reported a 5-year satisfactory result in 73% in 15 patients. Because this is a type of resection arthroplasty, it is not surprising that it was used as a salvage for infection in 87% of his patients.

Interposition arthroplasty is the earliest form of arthroplasty and was initially used at the temporomandibular, shoulder, wrist, knee, and hip joints. The elbow was second only to the temporomandibular joint as the joint most amenable to the technique. In Europe the procedure was used by Putti and Payr. Schüller was the first to recommend the procedure for patients with rheumatoid arthritis. The nature of the interposition represents a colorful page in the history of arthroplasty. Various muscle flaps, pig bladder, fascia-fat transplants, skin, kangaroo tendon, and other biologic materials have been used as the interposing agent. In 1902 Murphy introduced and popularized arthroplasty in the United States. Lexer, in 1909, emphasized the value of autogenous tissue and confirmed the impression of Murphy that fat and fascia were the best substances for interposition arthroplasty. He reported that fascia remained viable and was replaced by fibrous and fibrocartilaginous tissue. In our experience and in the experience of others, with time the interposed tissue disappears at the point of contact.

Interposed Tissues

As early as 1913, autogenous or xenograft cutis was successfully used (cutis arthroplasty) at various joints, and especially at the elbow. Cutis is the thick dermal layer of skin that remains after the superficial epidermal layer has been removed. It is a tough, durable, elastic membrane, and it closely adheres to the cut surface of the distal end of the humerus.

Fascia lata is easy to harvest and conforms readily to the bony surfaces, but the donor site has variable morbidity. Efforts to enhance its effect have been reported by Kita using chromicized fascia lata, the so-called J-K membrane.

In 1979 Shahriaree et al. reported that of 30 patients, 90% returned to their previous occupations after excisional arthroplasty with Gelfoam interposition. Smith et al. successfully used silicone sheets as interposition material in six patients with hemophilic arthropathy.

Today the procedure is performed most commonly with a substantively and readily available Achilles allograft with the addition of three important features to the technique: stabilization, distraction, and protected motion.

Indications

Contraindications

Acute or subacute infection is a contraindication for all reconstructive procedures. The procedure should be delayed until growth is complete. Inadequate bone stock or nonunion can sometimes be addressed with bone graft augmentation staged or simultaneous with the interposition.

Of practical note, we have found gross instability, deformity, and marked pain, especially at rest, are all associated with poorer outcomes. The patient with a grossly unstable elbow from rheumatoid arthritis or posttraumatic arthritis cannot be adequately stabilized by an interposition procedure. Congenital ankylosis of the elbow joint that lacks the necessary ligamentous support may be treated with interposition and ligamentous reconstruction. However, the absence of flexion motor power is an absolute contraindication to this procedure. The need to use the upper extremity for load bearing is a relative contraindication because excessive loading of the elbow destabilizes the joint.

If the patient is a heavy laborer, interposition arthroplasty may not be as satisfactory as a painless arthrodesis of the elbow in a functional position. Although interposition arthroplasty offers the patient a relatively pain-free durable joint, it cannot guarantee enough stability to allow the activities of heavy labor. If multiple joints in the same extremity have become ankylosed, it will be more difficult to secure a satisfactory result.

Finally, it is of utmost importance that the patient have the motivation and fortitude to participate in a preoperative and postoperative rehabilitation program for proper rehabilitation of the musculature of the upper extremity.

Preferred Tissue

Autogenous skin and fascia and Achilles tendon allografts have all been used by the author. The cutis is very durable and thick, rapidly adheres to the bone, and has generally been used successfully. The harvest techniques are attractive in those patients in whom primary closure may be performed. Cutis tissue without the epidermis is somewhat more difficult to harvest. Fascia is also commonly used because it is readily available from the thigh and can be overlapped to ensure adequate bulk. Recently other processed tissues such as AlloDerm (LifeCell, Branchburg, NJ) are being investigated for this purpose. Most recently the use of lateral arm fascia has been described in a single case report. At present, we prefer the Achilles tendon allograft because it is readily available. The following anatomic features are required for success of the procedure: absence of donor site morbidity, large size and thickness, sufficient material for ligament reconstruction if necessary, and presence of the calcaneus if an osseous graft is required.