Revision total elbow arthroplasty with interpositional fascial
1. Left failed total elbow prosthesis.
2. Rheumatoid arthritis.
1. Left elbow interpositional fascial arthroplasty.
2. Left elbow removal of deep hardware.
3. Dupuytren contracture release, left ring finger.
ANESTHESIA: Preoperative interscalene block supplemented by laryngeal mask airway anesthetic.
INDICATIONS: Patient is a pleasant 69-year-old gentleman, long-term patient of mine with rheumatoid arthritis. He is status post bilateral total elbow replacements. These were done over 10 years ago. The left has gone on to increased loosening, and the pain has gradually gotten to the point where he desires surgical intervention. We discussed treatment alternatives in detail. He has a fair amount of bone loss distally and appears to have a loose humeral and ulnar prosthesis. He has requested to go ahead with interpositional arthroplasty, since that is what we did on his right side inadvertently after his elbow had become infected following revision total elbow surgery. Risks and benefits were explained in detail to him and after all his questions were answered, he signed informed consent to proceed. Specifically, we also talked about releasing his left ring finger Dupuytren contracture, which has caused a 35-degree flexion contracture of the metacarpophalangeal joint and an early 10-degree contracture of the proximal interphalangeal joint.
PROCEDURE IN DETAIL: Under interscalene block with laryngeal mask airway general, the left arm was prepped and draped in the usual sterile fashion. We placed a tourniquet high on the left arm prior to this. Following a formal timeout session, we began. I did inject a dilute solution of 0.25% Marcaine without epinephrine in a circumferential fashion.
Utilizing the previous well-healed incision, I incised longitudinally. I spread down with Stevens scissors. I identified the medial intermuscular septum and gently spread down with Stevens until I had identified the ulnar nerve. Staying well radial to this, I sharply came down through the capsule subperiosteally. I then worked proximal to distal and distal to proximal, exposing the entire proximal ulna and proximal humerus. I then subluxed the tissues radially, allowing me to visualize the locking device between the ulnar and humeral prosthesis. I was then able to pop this out and easily remove the ulnar prosthesis with just finger pressure.
The humeral prosthesis was still reasonably well fixed. I had to do some circumferential thin osteotomes until I finally loosened it sufficiently to remove it. Back taps with the mallet and hook finally set the prosthesis free.
OPERATIVE FINDINGS: While there was some fluid within the joint, nothing appeared purulent. I did send some tissue for culture for academic reasons, but did not suspect a deep infection. There was some mild metallosis posteriorly, which I excised with a rind of synovium. I then curetted both the femoral and ulnar canal and pulsatile irrigated.
I then ranged the elbow. I found it actually quite stable to full extension and flexion to 130 degrees. The tissues kept it in line quite nicely as I did not have to fully release the epicondyles in order to remove the prosthesis. I did reapproximate some local tissues across the joint to serve as a fascial arthroplasty.
I then repaired the posterior capsule with interrupted #1 Vicryl suture. Care was taken to make sure I did not inadvertently capture the ulnar nerve. Subcutaneous reapproximation included 2-0 Vicryl, and staples were used to close the skin.