Session IX - Upper Extremity

Optimal Position for Elbow Arthrodesis

Chris Tang, MD; Nikolaos Roidis, MD; John Itamura, MD; Suke Vaishnau, MS; Chris Shean, MD; Milan Stevanovic, MD, LAC+USC Medical Center, Los Angeles, CA

Introduction: Elbow arthrodesis is a rarely performed salvage procedure. Most authors recommend 90° of flexion as the best position for fusion. The variables in the studies that have been reported are usually three: preferred positions for elbow fusion, range of elbow motion needed for specific task completion, and percentage of task completion in different elbow positions. The purpose of our study was to combine the assessment of the previous variables in a single study. We hoped to determine the best position of elbow fusion within the functional range of motion that would enable patients with normal range of motion to all other joints of the upper extremity to perform the most every-day activities with the least amount of difficulty.

Methods: A total of 24 volunteers, aged 18 to 35 years, were recruited for this study. There were 21 right-hand dominant and three left-handed, 11 women and 13 men. The elbow of the volunteers was immobilized with a functional brace in different positions throughout the whole range of motion of the joint in a sequential manner of 20° increments (30° to 130°, six positions). The amount of elbow flexion was verified before and after brace application by a goniometer, with use of the lateral epicondyle as the referenced axis of rotation. Maximum range of elbow flexion/extension with the brace in place was measured with a goniometer and found to always be <5% in each direction. Subjects then were asked to score the difficulty for each task performed. The average scores for personal care hygiene tasks (PCH), activity of daily living (ADL), and total functional scores (PCH+ADL) for each one of the elbow flexion positions were obtained. Results were statistically analyzed.

Results: The functional scores increased with increasing elbow flexion, peaking at 110° and then tapering down. The average functional scores reached their highest values at 110° of elbow flexion (PCH = 15.1, ADL = 16.0, PCH+ADL = 31.1) followed by flexion at 130° (PCH = 13.2, ADL= 15.6, PCH+ADL = 28.8), then 90° (PCH = 12.9, ADL= 13.4, PCH+ADL= 26.3). Statistical analysis revealed significant differences between the two groups with the highest functional scores (90° and 110°). Pair-wise comparisons between the 90° and 110° flexion groups demonstrated significantly higher mean functioning scores for ADL (P < 0.001) and combined PCH + ADL scores (P <0.001) for the 110° group. The mean PCH score was higher in the 110° group as well (P = 0.002).

Conclusion: The choice of position for elbow arthrodesis should be a patient's decision according to his or her specific needs. The optimal fusion position seems to be 110° for most activities and mainly upper extremity tasks whereas 45° to 60° is optimal for work-related activities. The patient should be informed about the choice between these two potential positions. A preoperative trial period with the elbow in a cast to ascertain the position of the greatest patient satisfaction is strongly recommended.