Shoulder and Elbow Cases to Consider.

Last updated Friday, February 11, 2005

Figure 1

Figure 2

Unconstrained total elbow arthroplasty for rheumat

Clinical presentation

This is the radiograph of a 60 year old woman with chronic rheumatoid arthritis who presented to us with problems 4 weeks after left total elbow arthroplasty. She had a similar procedure performed on the opposite side without problem. One week after this surgery she felt a "clunk" in her elbow and then had difficulty moving it without discomfort. Radiographs showed the elbow had dislocated (see figure 1). A closed reduction was performed, but 2 weeks later the dislocation recurred. Open reduction and a soft tissue reconstruction was performed at that time. Now the elbow is again dislocated, swollen and painful on all motion--she keeps it in a splint at all times. Her lateral elbow incision is relatively calm, but the sutures are still in place. She has had two surgeries and one manipulation in less than one month. Her exam indicates ulnar nerve irritation, but she is otherwise neurovascularly intact.

Our concerns included:

1. the patient's loss of elbow function
2. wound status
3. neurovascular status
4. risks of revision of cemented prosthesis in soft rheumatoid bone
5. incisional approaches

Management

Closed reduction was attempted under anesthesia and fluoroscopy. This could not be accomplished.

Open reduction was attempted after ulnar nerve dissection through a new posteriormedial approach. A stable reduction could not be achieved. Revision to constrained total elbow was accomplished with minor penetrations of ulna and humerus in process of cement removal. Post operative range was 0-135 degrees. Neurovascular status intact. See post operative radiograph (figure 2).

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