[Total elbow joint allograft for long term posttraumatic osteoarticular loss. Follow-up results at twelve years].
OBJECTIVE
Elbow joint allograft (EJA) involving the entire joint (distal humerus, proximal radius and ulna, capsuloligament structures) is a salvage technique proposed in massive bone loss, particularly in young subjects where total elbow prosthesis is contraindicated. We report our experience with seven patients, analyzing the long-term clinical and radiological outcome.


METHODS
This retrospective study included seven patients, mean age 42 years (21-70). All had experienced severe elbow trauma. Two patients had associated neuromuscular or vascular lesions. All patients underwent at least one surgical procedure on the affected elbow. The preoperative status of the skin cover was crucial. Both longitudinal and circumferential retraction were observed. We used preoperative skin expansion in one patient and a pediculated musculocutaneous latissimus dorsi flap in one other. A posterior and median approach was used conserving tricipital continuity. The ulnar nerve was transposed anteriorly. The allograft was prepared, carefully preserving the capsule and ligaments. Adaptation required cutting the extremities of the humerus and radius and total resection of the radial head except in one patient. Stable plate fixation was completed by an iliac cancellous graft screwed to the humerus and the ulna. The Morrey score was used to assess clinical outcome. The Larsen and Allieu classifications were used to assess radiological outcome.


RESULTS
There was one early failure requiring revision for arthrodesis. Assessment of long-term outcome concerned six patients. Mean follow-up was 12 years (7-15 years). The Morrey score improved in six patients and five of them were satisfied. None of the patients complained of invalidating pain and elbow motion was not functional in only one (- 30 degrees - 100 degrees ). For all patients except one, instability was proportional to the duration of the graft and worsened with time. For five out of six patients, significant radiological degradation of the elbow joint was associated with bone lysis which increased with time.


CONCLUSIONS
The allograft acts like a spacer and does not transmit pain impulses. The absence of the pain signal leads to overuse of the grafted joint and osteoarticular destruction. Despite radiological degradation, this procedure provides satisfactory and painless elbow function in most patients. The clinical and radiological features do not follow the same pattern. But we did not have any cases of disassembly or nonunion. Preoperative planning and plastic surgery have enabled us to control the cutaneous portal. We did not have any postoperative infections. Joint allograft is a salvage solution for major osteoarticular loss in young patients desiring conserved joint function and for whom a total elbow prosthesis is contraindicated. It restores bone stock, enables mid-term potential for joint function, and does not compromise surgical revision.


CONCLUSIONS
It remains an exceptional indication which is technically difficult. Resorption of the allograft is constant at long term. Clinically, instability worsen functional outcome. The future for this technique depends on progress in immunology and cryobiology. At the present time, composite total elbow prostheses with an allograft combine the advantages of restored bone stock and arthroplasty.
Allieu
Y
Y
Institut Montpelliérain de Chirurgie de la Main et du Membre Supérieur (IMM), 1133, rue des Bouisses, 34070 Montpellier.
Marck
G
G
Chammas
M
M
Desbonnet
P
P
Raynaud
J-P
JP
D000328:Adult; D000367:Age Factors; D000368:Aged; D019643:Arthroplasty, Replacement; D001862:Bone Resorption; D000075202:Contraindications; D015925:Cryopreservation; D004551:Elbow Joint / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006801:Humans; D006811:Humerus / Q000601:surgery; D007085:Ilium / Q000637:transplantation; D008297:Male; D008875:Middle Aged; D010027:Osteotomy; D018579:Patient Selection; D011859:Radiography; D011884:Radius / Q000601:surgery; D016059:Range of Motion, Articular; D012086:Reoperation; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000379:methods*; D012720:Severity of Illness Index; D013524:Surgical Flaps; D014184:Transplantation, Homologous / Q000379:methods*; D016896:Treatment Outcome; D000092464:Elbow Injuries