Salvage Operations for the Shoulder and Elbow

Indications

The goal of shoulder arthrodesis is to give the humerus stability in a functional position that allows optimal use of the distal upper extremity. The indications for shoulder arthrodesis have declined over time given the success with shoulder arthroplasty to treat a wide variety of end-stage shoulder conditions as well as the near eradication of poliomyelitis and tuberculosis, and improved techniques to treat shoulder fractures and instability. However, shoulder arthrodesis remains a successful treatment option for certain conditions including paralytic conditions, combined insufficiency of the rotator cuff and deltoid, recalcitrant instability, and chronic infections. Given the advancements in shoulder arthroplasty, other less common indications include failed shoulder arthroplasty, arthritic conditions in young, active patients unsuitable for arthroplasty, and neoplastic lesions. Current indications are listed in Box 13.1 .

One of the most common indications, currently, for shoulder arthrodesis is paralytic disorders of the upper extremity, including obstetrical brachial plexus injuries and traumatic brachial plexus injuries. When nerve repair, nerve grafting, and tendon transfers have failed or are contraindicated, shoulder arthrodesis may be indicated. Obstetrical brachial plexus injuries can be treated with arthrodesis near skeletal maturity when growth arrest and position changes are less of a concern. Some authors recommend combining shoulder arthrodesis with transhumeral amputation and prosthetic fitting in patients with complete brachial plexus palsy. Although a minimum age of 10 to 12 years has been suggested, in a review of shoulder arthrodesis in 102 patients, significant growth arrest occurred in only one child. Early arthrodesis has been advocated for children older than 6 years of age who have an irreversible flail shoulder with adequate scapulothoracic muscles, intact elbow flexors, and a functional hand with skin sensation. Finally, shoulder arthrodesis can be used in adult patients with flail limbs caused by persistent traumatic brachial plexus injuries. Wong et al. reported glenohumeral arthrodesis using a reconstruction plate in 6 patients, all of whom achieved fusion, with 5 reporting satisfactory pain relief. Ruhmann et al. reported 77 patients with persistent brachial plexus palsies treated with either trapezius transfer or shoulder arthrodesis. In the 14 patients who had arthrodesis, average abduction improved from 9.6 to 59.3 degrees and average forward elevation improved from 11.4 to 50.7 degrees postoperatively. Complications that necessitated multiple revisions and ultimately led to a poor outcome occurred in 1 patient.

In patients with combined deltoid and rotator cuff paralysis or insufficiency, arthrodesis is indicated over arthroplasty. With deltoid deficiency, the muscle power required to achieve adequate function after arthroplasty is lacking and complication rates are high. In patients with chronic infections, arthroplasty is contraindicated, and arthrodesis with limited internal fixation, with or without external fixation, often is the preferred salvage option. In these patients, though, it is important to adequately debride the shoulder of any infected tissue or bony sequestra in an attempt to minimize the infectious load and increase the chance of successful union. Patients with persistent shoulder instability after multiple failed procedures generally have deficiency of all capsulolabral structures with or without deltoid deficiency. These patients generally have inferior subluxation of the humeral head leading to painful instability, and arthrodesis in these patients gives a stable shoulder with low levels of pain.

Shoulder arthrodesis may be indicated after malignant tumor resection when soft tissues do not allow endoprosthetic reconstruction. Bone graft is required, and Bilgin et al. described the use of a vascularized free fibular autograft to augment bony healing in this situation. Massive bone loss also may be encountered in arthrodesis following failed shoulder arthroplasty when revision is impossible. Scalise and Iannotti described the use of different bone graft techniques to achieve shoulder arthrodesis. Additional procedures frequently are required to obtain union, and caution should be used in these complex patients. Others have reported acceptable outcomes with resection arthroplasty, which may be preferable to arthrodesis because of the technical difficulties associated with that procedure. In general, a physical laborer who is not required to routinely perform overhead lifting is the ideal candidate for shoulder arthrodesis.

Success after shoulder arthrodesis requires a functional scapulothoracic articulation. Given this, functional scapular stabilizers, including the trapezius, serratus anterior, and levator scapulae, are paramount, and paralysis of this musculature is a contraindication to shoulder arthrodesis. In particular, the trapezius and levator scapulae are responsible for shoulder abduction and the serratus anterior is responsible for forward elevation after shoulder arthrodesis. Other contraindications include ipsilateral elbow arthrodesis or contralateral shoulder arthrodesis, which produce significant functional deficits with activities of daily living, and Charcot arthropathy, which has an unacceptable nonunion rate.

Position

The proper position of the arm at the time of arthrodesis ( Fig. 13.2 ) remains controversial ( Table 13.1 ). Currently, most authors prefer 10 to 20 degrees of abduction, 10 to 20 degrees of flexion, and 35 to 45 degrees of internal rotation. This position allows the patient to reach the mouth, waist, back pocket, and contralateral shoulder, facilitating activities of daily living. The position of rotation is the most crucial factor in obtaining optimal function. One study found that more than 15 degrees of flexion and rotation of either less than 40 degrees or more than 60 degrees constituted a malposition that required operative treatment. Another study suggested that abduction of approximately 35 degrees and forward elevation of 30 degrees provided optimal functional results, but that internal rotation of more than 45 degrees should be avoided to prevent problems with hand-to-face activities.

Abduction can be determined at the time of surgery by clinically measuring the angle formed by the body and the humerus. Alternatively, this angle can be determined by obtaining an anteroposterior radiographic view using the spine rather than the border of the scapula as a landmark. Flexion is determined by observing the angle that the humerus forms with the horizontal plane in a supine patient. After the positions of abduction and flexion have been determined, the elbow is flexed to 90 degrees. The hand is positioned over the ipsilateral area of the chest between the sternum and axilla so that further flexion of the elbow allows the top of the thumb to touch the chin ( Fig. 13.3 ).

Surgical Techniques

Fusion of the glenohumeral joint, as well as between the humeral head and undersurface of the acromion, should be attempted, and numerous techniques have been described. Stable internal fixation can reduce the need for bone grafting, external fixation, or prolonged immobilization. Postoperative use of a premade custom orthosis to hold the position of the arm until fusion has been achieved is generally well tolerated by most patients and can be used for any of these techniques.

Shoulder arthrodesis without implants is primarily of historical interest. The techniques of Watson-Jones, Putti, Steindler, Brett, and Gill are not included in this edition because they are rarely indicated. For details of these techniques, the reader may refer to earlier editions of this textbook or the original articles.

Complications

Complications associated with shoulder arthrodesis are listed in Box 13.2 . Immediate postoperative complications are uncommon and mainly involve wound problems, such as infection, skin breakdown, and wound hematoma. The surgeon must also be mindful of pressure sores if a spica cast is used. Loss of elbow motion has been reported but is usually temporary as long as the elbow is not immobilized for more than 2 weeks.

Later postoperative complications are more prevalent. Malunion has been reported in up to a third of patients with shoulder arthrodesis. Malposition can lead to a traction neuritis or periscapular muscle strain, especially when the arm is positioned in too much abduction. A recent study reported an overall complication rate of 28%. Specifically, pseudarthrosis was more common when screw fixation was used, whereas infection, periprosthetic fracture, and symptomatic implants were more common when plates were used.

Nonunion rates in most modern series are less than 10%. Union is generally achieved with autologous bone grafting. Secondary degenerative arthritis of the acromioclavicular joint is common. If any signs of acromioclavicular arthritis are present preoperatively, a concurrent distal clavicle excision should be performed.

Ipsilateral humeral fractures after shoulder fusion have been reported in 25% of patients in some series. Most authors recommend nonoperative treatment with a shoulder spica or orthosis in these patients.

Outcomes

There has been a paucity of literature detailing the long-term outcomes of shoulder arthrodesis. Dimmen and Madsen reported 18 patients who had shoulder fusion using plate fixation. All obtained full or partial arthrodesis, and at an average 8-year follow-up the mean Oxford shoulder score was 32 and the mean American Shoulder and Elbow Surgeons (ASES) score was 59. Complications were uncommon: one patient required reoperation because of severe pain and one for a postoperative humeral shaft fracture; one patient had complex regional pain syndrome. In 21 patients who had shoulder arthrodesis as a primary or secondary procedure after tumor resection, Fuchs et al. found no local recurrences and no metastatic disease at an average 11-year follow-up. The average Toronto Extremity Salvage Score was 81% and the average Musculoskeletal Tumor Society score was 23. However, 43% of patients developed a complication that required additional surgical intervention. Another study by Miller et al. (2011) reported the outcomes of shoulder arthrodesis in 11 children (13 procedures) with flail shoulders caused by polio. At an average follow-up of 41 months, all patients were satisfied and pain free with improved shoulder function. Six patients underwent implant removal, and two shoulders required humeral osteotomy for malrotation. In a larger series of 54 patients undergoing shoulder arthrodesis for brachial plexus palsy, Atlan et al. reported an ultimate fusion rate of 94% and average active abduction of 59 degrees at an average follow-up of approximately 3 years. Arthrodesis rates were improved with the use of a subacromial bone graft.

Indications

Although total elbow arthroplasty has become an accepted treatment for a variety of degenerative and traumatic elbow conditions, concerns regarding its durability in young and/or high-demand patients make elbow arthrodesis an acceptable alternative in this population. Although partially mitigated by the ability of adjacent joints to compensate for lack of elbow motion, significant functional disability, particularly with self-care and activities of daily living, is common. As a result, total elbow arthroplasty, fascial arthroplasty, or even resection arthroplasty in the presence of functional musculature often provides better function of the upper extremity than does elbow arthrodesis.

Indications for elbow arthrodesis are listed in Box 13.3 . In general, elbow arthrodesis is reserved for patients with painful arthritis who are not candidates for total elbow arthroplasty, especially individuals who place high demands on the upper extremities, such as manual laborers. Elbow fusion also is indicated for persistent infection, including tuberculosis, which historically was the main indication for this procedure. More recently, elbow arthrodesis has also become recognized as the optimal treatment for massive upper extremity trauma seen on the battlefield. Typically, a combined internal and external fixation technique is recommended because of the extensive soft-tissue injury that is usually associated with such injuries.

For unilateral arthrodesis of the elbow, a position of 90 to 100 degrees of flexion is desirable to provide the most powerful grip strength. There is no ideal fusion position for all patients; the optimal position depends on whether occupational activity or self-care is the primary goal, as well as on the mobility of the contralateral arm. Simulation of arthrodesis by use of preoperative splints or casts set at varying degrees of flexion has been recommended.

Bilateral elbow arthrodesis rarely is indicated because of resultant functional limitations. If indicated, one elbow should be placed in 110 to 120 degrees of flexion to permit the patient to reach the mouth, and the other should be placed in 45 to 65 degrees to aid in personal hygiene. These positions can be varied to meet the requirements of the patient’s occupation.

Arthrodesis of the elbow joint is difficult because of the unique bony anatomy of the elbow and the long lever arm of the upper extremity distal to the elbow. For successful elbow arthrodesis, adequate bone stock must be present, although resection of the radial head may be necessary to preserve pronation and supination, and internal or external fixation with bone grafting is typically required.