Interpositional elbow arthroplasty using fascia lata autograft in stiff elbow: Case series of 8 patients

Abhimanyu Kumar; Loveneesh G Krishna

doi:10.1016/j.jcot.2021.03.013

. 2021 Mar 24;17:201–213. doi: 10.1016/j.jcot.2021.03.013

Interpositional elbow arthroplasty using fascia lata autograft in stiff elbow: Case series of 8 patients

Abhimanyu Kumar ^a,^∗, Loveneesh G Krishna ^b,^c

PMCID: PMC8048033 PMID: 33898240

Abstract

Introduction

Constrain of a total elbow replacement and elbow arthrodesis are too much for the working population to bear. As such interpositional elbow arthroplasty using fascia lata autologous graft to reconstruct the elbow joint is a viable option in this age group.

Materials and method

8 patients were operated for arthritic stiff elbow, and joint reconstruction was done using fascia lata autologous graft, with out the use of any hinged external fixator. Pre-operative and post-operative functional assessment was done using Mayo Elbow Performance Score (MEPS) and statistically measured using a paired t-test.

ResultThere was significant improvement in range of motion in coronal (flexion-extension) and axial (supination-protonation) with p-value of <0.001. The mean pre-operative MEPI increased from 40.6 points to 91.9 points (p < 0.0001). All parameters of MEPI had statistically significant improvement with exception of stability (p-value = 0.0824).

Keywords: Elbow interpositional arthroplasty, Fascia lata autograft, Stiff elbow, Bone stock preservation, Elbow arthroplasty, Elbow arthritis

1. Introduction

Osteoarthritis of the elbow occurs when the cartilage surface of the elbow is damaged or becomes worn. This can happen because of a previous injury such as elbow dislocation or fracture. It may also be the result of degeneration of the joint cartilage from age, inflammatory diseases like rheumatoid arthritis or infection of the elbow joint. Despite having a functional upper limb with good hand and shoulder functions, the patient is not able to use the limb to its optimal capacity because of the arthritis of the elbow. Basic daily activities like combing hair, buttoning the shirt, tying shoe laces and even putting food in mouth becomes difficult. Currently, the only options available are elbow arthroplasty and elbow arthrodesis. Because of known complications of replacement arthroplasty of elbow, there is no consensus in treatment of arthritic elbow.¹ Interpositional arthroplasty has evolved from Hass functional arthroplasty, which is actually a modification of resection arthroplasty.² Stability of elbow joint depends the ligamentous congruity of the joint. The importance of ligamentous stability cannot be over emphasized in the functionality of elbow joint. Although semi-constrained total elbow arthroplasty has good early results, longevity and concerns with revision and infection limit its use in younger, more active patients. The interpositional arthroplasty takes care of both the factors responsible for the functional output of elbow joint i.e., reconstruction of a congruent articular surface and maintenance of ligamentous sleeve around the elbow joint. We present a series of eight patients with elbow arthritis treated with interpositional elbow arthroplasty and their functional result.

2. Materials and method

This is a short-term study conducted in a tertiary care hospital. We were able to identify and include eight patients (five males and three females) with stiff elbow in this study. Patient’s age ranged from 22 years to 53 years (mean: 41.1 years). Post-traumatic arthritis was the cause of painful stiff elbow in six patients, while two were suffering from rheumatoid arthritis. All patients were right hand dominant. Seven patients had stiffness in right elbow, and one had stiff in left elbow. There was no ankylosis or gross instability in any elbow. Pain, associated with stiffness, defined as limitation of functional range of motion (100° of flexion-extension arc and 100° supination-pronation arc), were primary complains and indications for surgery.

Loss of articular congruency was confirmed on radiograph, and CT (when required).

Patients were followed up for minimum of 9 months with mean of 26.4 months (range: 9 months–60 months).

Mayo Elbow Performance Index (MEPI) was used for functional elbow scoring.

3. Statistical analysis

The differences in outcome measures before and after surgery were examined using a paired t-test. The difference was considered significant when p-value was <0.05.

4. Operative technique

The senior author (LGK) was primary surgeon in all the cases. All surgeries were performed under general anesthesia after taking informed written consent from the patients. Patients were positioned in the lateral decubitus position depending upon the side involved. A curvilinear longitudinal posterior mid-line incision was given over the involved elbow taking care to miss the bony prominence formed by the olecranon (Fig. 1). Ulnar nerve was identified and dissected out of the operative field. The triceps aponeurosis was reflected from the muscle as a tongue shaped triangular flap with base attached to the olecranon (Fig. 2). Triceps muscle was split in the mid-line and the origin of the common extensor muscles and of the lateral ligament complex are released from their origin on the humerus as osteo-periosteal flap and the whole of the elbow joint was exposed by supinating the forearm and applying varus stress at the elbow. Medial collateral ligament complex was left intact (Fig. 3).

Fig. 1 — Curvilinear posterior incision.

Intra-operatively, all had more than 50% erosion of trochlea, capitellum, radial head and olecranon. Radial head was not excised in any patient. Greater sigmoid notch was intact in all patients.

The articulating surface of distal humerus and the ulna was prepared using an oscillating saw and burr to give them their native contour without removing much of the bone from either surface. Distal humerus (capitellum and trochlea), olecranon and radial head were prepared by shaving of the remaining articular cartilage and minimal subchondral bone to maintain the bony contour of trochlea and capitellum as well as olecranon to provide inherent bony stability to the elbow. The head of radius as well as the cartilage over radial head was preserved in all cases (Fig. 4).

Fig. 4 — Remaining arthritic cartilage removed, and subchondral bone preserved.

5. Preparation of fascia lata auto-graft

Because of the lateral position of patient, the fascia lata graft was prepared form the ipsilateral thigh. Fascia lata was approached through a lazy-S shaped longitudinal incision over middle and distal third of the thigh. Fat over the fascia lata was mobilized on either side to expose the fascia. Required area of fascia lata was marked and excised in a rectangular manner. We tried to harvest a minimum of 18 cm by 5 cm of fascia lata (Fig. 5). In order to close the defect, multiple staggered incisions were given on both sides of the defect, which helped in approximating the defect in fascia lata. We did not try to completely close the defect. Wound was closed over drain.

6. Application of fascia lata auto-graft

Drill-holes were placed at the medial and lateral ends of the humeral condyle from posterior to anterior directions proximal to the leading edge of the joint and at the edges of the olecranon joint surface. The fascia lata graft is first folded around the humeral condyles and reflected on to the olecranon joint surface and the radial head like a water-fall and fixed by using number-2 braided non-absorbable trans-osseous mattress sutures in such a manner that its the outer smooth surface forms the new joint surface of the elbow joint, and the raw bony surface of the distal humerus and olecranon is covered by the inner surface of fascia lata. Before suturing the fascia lata graft to olecranon sufficient tension is given to the graft to prevent it from loosening and forming folds in the joint (Fig. 6).

Fig. 6 — Fascia lata placed and sutured over distal humerus and olecranon (∗olecranon, solid arrows: reflected triceps muscles, curved line: distal humerus with fascia lata graft).

We did not use external fixator to distract the joint in any of the cases. Intra-operative stability was checked with the elbow in flexion and in extension. Radial head movements were assessed after relocation of elbow with respect to the newly formed radio-capitellar joint and radio-ulnar articulation. Lateral collateral ligaments were repaired using number-2 non-absorbable trans-osseous sutures and elbow was again checked of instability. Wound was closed over negative suction drain and above elbow posterior splintage was given with elbow positioned in 90° flexion and neutral rotation.

7. Post-operative care

The operated limb was immobilized in an above-elbow splint for 2 weeks. Elbow joint was passively mobilized under supervision at the time of first post-operative dressing, usually on day 3 of surgery. Stiches were removed at 2 weeks and patients were given functional elbow brace after assessment of elbow stability at the end of 2 weeks. Physiotherapy was started at this time with brace in place in the form of range-of-motion exercises of elbow, shoulder and wrist. DMARDs were restarted in rheumatoid patients after suture removal. At the end of 6th post-operative week, elbow range-of-motion exercises were continued with 1 kg of weight in hand. Here, patients were allowed to return back to their daily routine activities with restriction of lifting more than 1-kg weight. Functional elbow brace application was advised at rest only (night) till 3 months. Range-of-motion exercises were continued with gradual increase in weight every two to three weeks. Brace was discontinued after 3 months.

8. Follow up

Patients were followed up in out-patient department at 2 weeks, 6 weeks, 3 months, 12 months and 18 months, and then at the discretion of the patient and primary surgeon if required. Elbow functional scoring was done using Mayo Elbow Performance Index (MEPI) in each follow up assessing movement, pain, stability and the functions of daily living.

9. Results

Elbow was stable in all patients in the post-operative period but was supported by a posterior splint till stiches were removed and later, by a functional splint.

Ulnar nerve functions were intact in all patients pre-operatively and remained so after surgery.

Clinical assessment was done using the cohort of eight patients with fascia-lata auto-graft in place. No re-surgery was required to be done during the follow up period.

Pre and post-operative assessment was done using MEPI with post-operative MEPI done at the latest follow up. Pre-operatively, the mean arc of motion in coronal plane was 28.1° (range: 10°–50° arc) and the mean range of motion was from 45.6° short of full (range: 15°–80°) to 73.75° of flexion (range: 40°–110° of flexion). [Fig. 7 (a) and (b), Fig. 8(a) and (b)] Post-operatively, at the time of last follow up (mean: 26.4 months) the mean range of motion was from 5° short of full extension (range: 0°–10°) to 123.1° of flexion (range: 110°–135°), for a mean arc of 118.75° (range: 100°–130°), with a mean improvement of 90.65° (p < 0.001) [Fig. 9(a) and (b)]. Preoperatively, the mean protonation was 26.2° (range: 10°–40°) and the mean supination was 18.1° (range: 10°–30°), creating a mean arc of 44.4° (range: 30°–60°). Postoperatively, the mean protonation was 53.75°, and the mean supination was 50°, creating a mean arc of 105°. This increase in pronation-supination was significant (p < 0.001).

Fig. 7 — Flexion and extension under anesthesia (pre-operative).

Fig. 8 — a) Pre-operative range of motion-flexion.

b) Pre-operative range of motion- Extension.

Fig. 9 — a) Post-operative range of motion- Flexion at 2 years.

b) Post-operative range of motion- Extension at 2 years.

On comparing pre-operative [Fig. 10(a) and (b)] and post-operative [Fig. 11] radiographs, a well-formed elbow joint was observed with preservation of most of the bony architecture of ulno-humeral and radio-humeral joints, which remained so after 2 years of follow up [Fig. 12(a) and (b)].

Fig. 12 — a) Post-operative Lateral view radiograph at 2 year follow up.

b) Post-operative antero-posterior view radiograph at 2 year follow up.

The mean pre-operative MEPI of eight patients was 40.6 (range: 20 to 60). The mean post-operative MEPI was 91.9 points (range: 75 to 100 points) (p < 0.0001). All parameters of MEPI had statistically significant improvement with exception of stability (p-value = 0.0824). (Table 1).

Table 1.

Pre-operative and Post-operative MEPS score.

MEPS Component	Points (Range)	Pre-operative Score (Mean Points)	Post-Operative Score (Mean Points)	Matched Pairs p-value
Pain	0 to 45	18.75	43.12	<0.0001
Motion	0 to 20	6.25	18.75	<0.0001
Activity	0 to 25	7.5	20	<0.0001
Stability	0 to 10	8.75	8.75	0.0824
Overall	0 to 100	40.6	91.9	<0.0001

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There was some instability of the elbow during initial follow up, because of which a hinged elbow brace was given and was discontinued after 3 months. One patient, who had post-traumatic arthritis in the non-dominant limb, had inferior out-come (MEPI of 80 each) as compared to others. Another patient who was non-compliant with physiotherapy had MEPI score of 75.

There was one donor site complication in the form of acute compartment syndrome of anterior compartment of thigh due to tight closure of donor site. At the time of the latest follow-up, all patients retained the same preoperative level of humeral bone stock.

10. Discussion

Elbow arthritis is a difficult problem in a young active individual as the surgeon is limited by the treatment options. Over the years, as our understanding of elbow anatomy and biomechanics evolved, so has the methods for dealing with elbow arthritis. These would range from non-surgical treatments like advising physiotherapy and medications in elderly patients with low day-to-day functional demand, to surgical management in relatively younger patients with high functional demands. There have been many advancements in surgical management of arthritic elbow, which is being continued to be developed even now. The quest to provide a stable, pain-free, mobile and functional elbow joint has always been overshadowed by the restrictions imposed by the present implants. The major concerns for the total elbow arthroplasty in young individuals are that they may require additional surgeries later due to implant loosening as a result of excessive wear and tear of the implant. This may be due to their involvement in strenuous activity and that; they are not able to tolerate the 5 kg weight lifting restriction after total elbow arthroplasty.³^,⁴ Resection arthroplasty and arthrodesis is also not well tolerated by the young patients even as salvage procedure.⁵

The goal of treatment is to restore a functional joint while preserving future surgical salvage options. Although described by many authors as a salvage procedure, the technique justifies its name as the whole of the native bone stock is salvaged for further procedures. Larson and Morrey (2008) published the largest know series of interpositional elbow arthroplasty till date in 38 elbows, using achillis tendon allograft as the interposed material with a mean follow up of 6 years. In their series, post-operative MEPS improved from 41 to 65, the authors observed that the procedure neither eliminates pain nor restores full function.⁷ Salvaging nature of the procedure can be under-stood by a case reported by Nadeem et al. (2020) who converted an interpositional elbow arthroplasty to TEA, 23 years after the primary procedure.¹⁸

Various materials have been described as interpositional grafts and include Achilles tendon allograft,⁶^,⁷^,²¹^,²²^,²³^,²⁵^,²⁸ cutis graft,⁹^,²⁹ Gelfoam,⁸^,⁹ Alloderm,¹⁰^,¹¹ bovine collagen,¹²^,²² fascia lata,⁹^,¹³^,¹⁴^,¹⁹^,²²^,²⁶^,²⁷ silicon,¹⁵ anconeus muscle²⁰^,²⁴ and triceps fascia.³⁰ Many researchers have also described the use of a hinged external fixator to stabilize the reconstructed elbow joint and allow for early movement of the joint.⁷^,¹⁰^,¹³^,¹⁴^,¹⁶^,¹⁹^,²¹^,²²^,²³^,²⁷^,²⁸ Based on our review of literature, interpositional elbow arthroplasty is associated with improved range of motion, less post-operative restrictions and more patient satisfaction outcome (Table 2). We have used fascia lata auto-graft to reconstruct the elbow joint without the use of an external fixator.

Table 2.

Review of literature regarding interpositional elbow arthroplasty.

Study	Number of patients	Graft material	Technique	Follow-up	Complications	Satisfaction/score
Fox et al. (2000)¹⁹	11	Fascia lata allograft	Open. External fixator.	2.4 years	Pin-site infection⁵	Flexion-extension arc: 55°–96° Satisfactory⁷ Poor²
Fox et al. (2000)¹⁹	11	Fascia lata allograft	Open. External fixator.	2.4 years	Ulnar Nerve paresthesia¹	Flexion-extension arc: 55°–96° Satisfactory⁷ Poor²
Cheng and Moorey (2000)¹³	13	Fascia lata distraction interposition	Open. External fixator.	5.3 years	Ulnar N palsies³ Thigh graft complications³ Pin site infection¹ Conversion to TEA⁴	MEPS 34 to 79 Excellent MEPS⁸ Satisfactory pain relief¹³
Morrey and Schneeberger (2002)²⁰	14	Anconeus interposition at radiocapitellar joint, Proximal radioulnar joint, or both	Open	6.1 years	Residual pain²	Satisfactory outcome subjectively,¹² MEPS 63 to 89 Flexion-extension arc: 89°–108°
Nolla et al. (2008)²¹	13	Achilles allograft	Open. External fixator distraction	4 years	Revisions/Failures² Pintract infection²	Broberg-Morrey: Excellent,¹ Good,⁴ Fair,⁴ Poor⁴ Flexion-extension arc: 48°–110° PS arc: to 142° DASH: post-operative 29
					Pin breakage, Radial N Palsy¹
					Ulna fracture requiring ORIF¹
Larson and Moorey (2008)⁷	45	Achilles allograft	Open	6 years	Revisions⁷: 2 infection, 4 instability. 1 pain	Flexion-extension arc: 51°–97°
						PS arc: 85°–123°
						MEPS 41-65
Fernandez-Palazzi et al. (2008)⁹	12	Fascia lata-10, Skin graft-1, gel foam-1	Open	28 years	Poor result³	Flexion-extension arc: ≥120,² 90–119°,³
						60–89°,⁴
						≤59°³
Laubscher et al. (2014)²²	17	Autogenic Fascia lata-1	Open. External fixator in 13 cases	54 (8–120) months	7 (4 TEA, 2 Arthrodesis, 1 re-do arthroplasty)	Flexion-extension arc: 16°–97° MEPS Pre-op 42 Post-op 76
		Triceps-2
		Bovine pericardium- 4
		TA Allograft-10
Ersen et al. (2014)²³	5	TA allograft	Open. External fixator.	7.3 years	1 radial nerve palsy	Flexion-extension arc: 24°–81°
						DASH: 75-19
						MEPS Pre-op 25
						Post-op 71 (p < 0.05)
Baghdadi et al. (2014)²⁴	29	Anconeus	Open.	10¹^,²^,³^,⁴^,⁵^,⁶^,⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵^,¹⁶^,¹⁷^,¹⁸^,¹⁹^,²⁰ months	Hematoma¹ Transient PIN palsy¹	MEPS Pre-op 64 ± 17
Baghdadi et al. (2014)²⁴	29	Anconeus	Open.		7 s surgery	Post-op 82 ± 14 (p < 0.001) qDASH Post-op 24
Chauhan et al. (2015)²⁵	4	TA allograft	Arthroscopy	3.6 (2.5–6) years	None	Flexion-extension arc: 68°–105° DASH Post-op 27
Chauhan et al. (2015)²⁵	4	TA allograft	Arthroscopy	3.6 (2.5–6) years	1 converted to TEA due to persistent pain after 2.5 years	Flexion-extension arc: 68°–105° DASH Post-op 27
Sivakumar et al. (2016)²⁶	2	Autogenic fascia lata	Open	22–24 weeks	Not mentioned	MEPS Post-op 75 and 65
Rollo et al. (2018)²⁷	1	Allogenic fascia late	Open. External fixator.	5 years	None	MEPS Post-op100
Blain et al. (2019)²⁸	1	TA Allograft	Open. External fixator.	12 weeks	None	MEPS not mentioned.
Ahmed et al. (2020)²⁹	17	Autogenic abdominal dermal graft	Open	22 (12–50) months	5 mid instability	Flexion-extension arc: 25–120. MEPS Pre-op 15-70
Ahmed et al. (2020)²⁹	17	Autogenic abdominal dermal graft	Open	22 (12–50) months	3 donor site hypertrophic scar	Post-op 85–100 (p < 0.01)
Iyidobi et al. (2020)³⁰	16	Triceps fascia	Open	24 weeks	1 Radial nerve neuropraxia	Flexion-extension arc: 16°–97°
						MEPS Pre-op 42.51
						Post-op 81.24 (p < 0.001)

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Autologous fascia lata graft was chosen because it was the safest graft in terms of any infection or reaction, and most easily procured without incurring any extra cost to the patient. There was no associated morbidity at the donor site after the graft was harvested well (except in one case). Giving staggered multiple splits in the fascia lata adjacent to the donor site caused the defect to close without any tension, thus, preventing any future risk of muscle herniation.

The decision for not using hinged external fixator after elbow reconstruction was due to the fact that none of the patients in our study came with gross elbow instability after the completion of procedure because the bone stock and the native contours of elbow joints were preserved. We only removed the remaining cartilage from the arthritic joint and preserved the native bony architecture of ulno-humeral joint. If at all, the joint was found to be incongruent, we removed only as much of the bone as was required to give the joint a normal congruent anatomy. Because of this, the joint remained stable at the end of ligament reconstruction and there was no need to use external fixator. That way, the physiotherapy and range of motion exercises was fully under our control. Also, early range of motion exercises built confidence in the patient and we were able to switch from early passive range of motion exercises to early active assisted range of motion exercises very soon after the surgery with out any fear of loosening of external fixator and pin tract complication.

Preserving the bone stock had the added advantage of ease of converting the interpositional elbow arthroplasty to a total elbow arthroplasty, if at all required in the future. Blain et al. who showed that failed interpositional elbow arthroplasty could safely be converted to a total elbow arthroplasty, have also supported this.¹⁷

In conclusion, we believe that interposition arthroplasty is a safe, intermediate-term procedure that preserves substantial bone stock for future revisions. We recommend the use of fascia lata auto-graft for reconstructing the elbow joint because of easy procurement, free from any reactions or cross infection and without any donor site morbidity. We, however, recommend the use of interpositional elbow arthroplasty in painful, stable elbow in young individuals where it can be used as an intermediate salvage procedure before a total elbow arthroplasty of fusion is planned.

11. Drawbacks of the study

There are a few drawbacks to the study. Firstly, the cohort comprised of a small group only. Secondly, some patients were followed up for only a short duration (9 months). A long-term study is planned in continuation of this study to know the long term out come of interpositional elbow arthroplasty. Thirdly, all arthritic elbows were stable pre-operatively, hence, this allowed for early rehabilitation of patients after the procedure.

Conflict of interest

There was no conflict of interest during the duration of this study.

Contributor Information

Abhimanyu Kumar, Email: drabhimanyukumar@gmail.com.

Loveneesh G. Krishna, Email: loveneesh_krishna@yahoo.co.in.

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PERMALINK

Interpositional elbow arthroplasty using fascia lata autograft in stiff elbow: Case series of 8 patients

Abhimanyu Kumar

Loveneesh G Krishna