Diagnosis and treatment techniques for elbow joint fixation surgery
1, Although maintaining elbow joint mobility is important for surgical indications, total elbow replacement has not yet been widely accepted like hip, knee, and shoulder replacement. The elbow joint movement disorder can be compensated to some extent by the function of adjacent joints. Due to the fact that the elbow joint is not a weight-bearing joint, fascial or joint excision is usually more effective than joint fixation when the surrounding muscles function well. Elbow joint fixation is suitable for patients with painful arthritis who are not suitable for total elbow replacement or joint shaping, especially those who require high upper limb strength, such as manual laborers. Elbow joint fixation is also suitable for persistent infections, including tuberculosis infections. Tuberculosis of the elbow joint was once the main indication for joint fixation. Elbow joint fixation is also a treatment option for severe and irreparable comminuted intra-articular fractures of the distal humerus. After the failure of total elbow replacement, elbow joint fixation can also be used as a remedial surgery. 2, Joint fixation angle: Unilateral elbow joint fixation, with a functional position requirement of 90 °. In 1992, O'Neill et al. reported on 10 healthy individuals using braces to simulate fixation of the elbow joint at 50 °, 70 °, 90 °, and 110 °, respectively, to determine the compensatory ability of other joints in the upper limb during elbow fixation. It was found that a fixed angle of 90 ° is most convenient for personal hygiene activities, while 70 ° is most ideal for activities outside of personal hygiene. There is no optimal fixed angle suitable for all activities. The preoperative use of splints to fix the elbow joint at different angles to simulate joint fixation has also been recommended by other scholars.
Due to its potential to cause severe functional limitations, bilateral elbow joint fixation has few indications. If necessary, one elbow should be fixed at 110 ° so that it can touch the mouth, and the other elbow should be fixed at 65 ° for personal hygiene. The functional position of the elbow joint may vary depending on the patient's occupation.
3, Due to the special anatomical structure of the elbow joint and the long torque of the forearm, the fixation of the elbow joint is somewhat difficult. To ensure the success of elbow joint fixation surgery, the fixed bone must have a certain quality. Even if the radial head must be removed to restore pronation and supination function, internal or external fixation and bone transplantation are still necessary. In the early elbow joint fixation technique reported by Hallock, the olecranon was excised and embedded in the distal posterior part of the humerus. Steindler applied tibial transplantation to embed the olecranon tip and fixed it to the distal humerus with screws. The basic points of Steidler's surgical method are as follows: make an incision on the lateral side of the elbow, cut the triceps at the insertion point of the olecranon process with a bone knife, and try to thoroughly remove the proliferative synovium while preserving other tissues. Then remove the half moon incision of the olecranon and the cartilage surface of the humeral trochlea, and clean the subchondral bone surface. Meanwhile, another surgical group removed 1.5cm wide and 9cm long transplanted bone fragments from the upper part of the tibia. Make a bone bed behind the lower part of the humerus to accommodate the transplanted bone, and create a bone groove at the tip of the olecranon. Insert the bone fragment into the bone groove while bending the elbow, then extend the elbow joint to the desired fixation angle and fix it to the posterior bone bed of the humerus. Use 1-2 screws to fix the transplanted bone to the humerus, and fill the humeral ulnar joint with cancellous bone taken from the upper end of the tibia. After surgery, the elbow joint was fixed in a 90 ° flexion position with the forearm in a neutral position using a long arm cast. After 8 weeks of surgery, it can be replaced with braces for fixation until bone healing.
Brittain introduced the fixation technique of using two tibial bone grafts to cross and lock the elbow joint in an X-shape. During this surgical operation, important anatomical structures will not be encountered, but when inserting the second bone graft from behind, it should not protrude too far forward. He believes that the safety range of this surgery is quite large, as the nerve vessels in the elbow have shifted forward during elbow flexion.
Koch and Lipscomb reported 17 cases of elbow joint fixation using various methods, of which only 8 were successful, while all 5 cases using the modified Britain surgical method were successful. Therefore, it can be considered that the Brittain surgery has a high fusion rate. The following is an introduction to its surgical method:
The patient is in a supine position, with the elbow bent 90 degrees. Two transplanted bone fragments measuring 7.5-10cm in length and 8mm in width are taken from the upper tibia. Make a 12.5cm incision behind the elbow, separate along this incision to the bone surface, expose and protect the ulnar nerve. Drill two vertically arranged holes on the olecranon process, with the first hole 6mm away from the tip of the olecranon and the second hole 1.8cm away from the tip of the olecranon. Use a bone knife to drill through the two holes to prevent bone splitting. Insert the bone knife into the proximal end and cross the elbow joint by 7.5cm, with a direction that is basically consistent with the longitudinal axis of the humerus and slightly inclined forward. Drill a hole slightly proximal to the olecranon fossa of the humerus using the same method. While retaining the first osteotome, insert the second osteotome in a direction that is aligned with the long axis of the ulna and slightly oblique to the long axis of the humerus. By retaining the first osteotome and inserting the second osteotome, the previous osteotome can be avoided, thus avoiding the bone graft blocks blocking each other in the tunnel. Take out the first bone knife, replace it with a slightly thicker bone knife, gently shake to enlarge the bone graft hole, use a bone holding forceps to insert the bone block into the bone graft channel by more than 1.3cm, and then drive it into the bone graft channel. Using the same method to insert the second bone graft, due to the tight insertion of the graft, the local bone surface can be affected
There may be some fragmentation, but due to pre drilling, severe splitting can be avoided. The postoperative treatment is the same as the Steindler surgical method.
Staples designed an elbow joint fixation method that extensively exposes the bone surface, increases contact with the bone graft, and fixes the bone graft to the humerus and ulna with screws. The key points of the surgical method are as follows: expose the elbow through a posterior incision, cut off part of the olecranon with a bone knife, divide the triceps tendon into inner and outer parts, and pull it apart from the attached olecranon bone block towards the proximal side. Remove the cartilage surface of the elbow joint, chisel a flat bone surface behind the distal end of the humerus, and make this surface adapt to the residual bone surface of the proximal end of the ulna. Fill the joints with broken bone pieces, fix the upper end of the bone graft and the humerus with a screw, chisel the olecranon for reduction, and fix it by passing a long screw through the olecranon, lower part of the bone graft, and upper end of the ulna. The postoperative treatment is the same as the Steindler surgical method.
Arafiles reported that 11 cases of elbow tuberculosis were successfully fixed. The operations included radial head resection, joint cleaning, synovectomy, and triceps olecranon bone block inserted into the corresponding bone canal at the proximal end of the humerus and fixed with screws. During surgery, bone transplantation is not performed, but it is recommended to move the ulnar nerve forward during fixation. The basic points of the Arafiles surgical method are as follows: make a straight incision behind the elbow with the olecranon as the center, expose the ulnar nerve and pull it apart, split the triceps tendon to the synovium and the insertion point of the tendon on the olecranon, perform synovectomy from the back, cut off the extensor and flexor muscles combined with the tendon from the inner and outer epicondyles, dislocate the ulnar humeral joint, remove the radial head near the protuberance of the biceps muscle, perform anterior synovectomy, use a saw to cut the olecranon into a triangle, and then make a triangular gap at the olecranon fossa to accommodate the trimmed olecranon. Insert the bone end of the olecranon into the repaired cavity on the humerus and remove excess bone. Inject diagonally from humerus to ulna
Bone screw. After surgery, the elbow joint was fixed with long arm plaster for 3 months, and then fixed with a removable splint for 1 month.
The AO school recommends using a combination of internal and external fixation methods for elbow joint fixation. External fixation compression instruments are combined with cancellous bone screws to fix the olecranon to the humerus. The basic points of the surgical method are as follows: expose the elbow joint from the posterior side, remove all cartilage and synovium from the distal humerus and olecranon, shape the proximal ulna into a square platform bracket, and cut the distal humerus into a suitable shape. Then, the radial head is removed at the level of the biceps protuberance, and a Kirschner wire is inserted into the humeral bone marrow cavity from the olecranon to temporarily maintain a fixed position, followed by fixation with cushioned cancellous bone screws. Then insert another transverse Kirschner wire into the humerus, add a fixation frame, and apply pressure. 6-8 weeks after surgery, the external fixation frame and Kirschner wire were removed, and the long arm plaster was replaced until clinical and X-ray results showed firm fixation.
Spier applied a wide AO steel plate bent into a 90 ° fixed elbow joint to successfully fuse the joint. He also suggested removing the radial head and cutting the humerus and ulna olecranon to form a shape similar to the AO surgical method. In 1992, McAudiffe et al. reported the application of AO compression plate technique for elbow joint fixation in 15 patients with high-energy fractures, open fractures, and infectious injuries accompanied by bone defects. Except for one patient who underwent amputation due to severe infection, all patients were successfully fixed.
4, Complications of elbow joint fixation include delayed healing, non healing, and malunion, which can cause nerve and vascular damage when using external fixation frames. Due to the lack of subcutaneous tissue behind the elbow, posterior surgery may result in pain and skin necrosis caused by fixed instruments
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