Cutis Autograft Interposition Arthroplasty of the Elbow: Twenty-Three Year Survivorship and Successful Conversion to Total Elbow Arthroplasty

Elbow arthritis can lead to significant upper limb dysfunction in everyday activities due to the elbow's key role in positioning the dominant hand. Osteoarthritis may develop in the elbow after overuse injury, trauma, osteochondritis dissecans, osteochondromatosis, crystal-induced arthropathies, and sequelae of septic arthritis or hemophilia [3] . Treatment options for primary or secondary elbow arthritis that disrupts function include arthroscopic debridement, arthrodesis, resection arthroplasty, interposition arthroplasty (IA) and total elbow arthroplasty (TEA) [6] . The use of membranous interposition or distraction in arthritic joints dates back to 1860 [29] . While fascia lata [ 5 , 13 ], cutis graft [10] , Achilles tendon allograft and AlloDerm (LifeCell, Branchburg, New Jersey, USA) are preferred materials, bovine collagen [16] , Gelfoam (Pharmacia and Upjohn, Kalamazoo, Michigan, USA), Ivalon sponge [7] , and silicone [28] have been used with success rates ranging from 26 to 94% [ 17 , 19 , 20 , 22 , 23 ]. The original concept has been further modified by hinged distraction external fixation, which allows for early motion while protecting the graft and healing ligaments from stretching or failing early on [ 5 , 9 , 30 ]. Soft tissue reconstruction of medial and lateral collateral ligaments as well as bone grafting make IA possible even in cases complicated by instability or bone loss [12] . Current IA surgical techniques have been described by Chen et al [4] . Active infection, open physes, and absence of flexor motor power are the main contra-indications [ 10 , 19 ]. Gross instability and/or deformity at rest are relative contraindications considering their association with poorer outcomes [18] . Historically, the classic indication for TEA is an inflammatory arthropathy that has invariably destroyed the elbow joint because outcomes have shown significant improvements in pain and function in these patients [11] . If joints are caught early enough in the course of Rheumatoid Arthritis, ligament integrity and bone stock are usually sufficient to allow for implant arthroplasty [25] . Additionally, as patients with a systemic joint disease, they are unlikely to be so physically active that mechanical failure would occur. Posttraumatic osteoarthritis of the elbow presents difficulties in management particularly because these patients are younger and more active. As younger patients are not considered prime candidates for TEA, this leaves many younger adults with posttraumatic elbow arthritis finding IA to be their best option. While TEA yields better average pain relief than IA, it imposes a weight lifting restriction beyond 5 kilograms and can therefore be unrealistic for young, active patients [24] . Furthermore, Schneeberger et al [27] reported a 27% complication rate in young patients undergoing TEA and Celli et al [2] reported a 37% revision rate within 7 years in young TEA-recipients, making TEA an unfavorable option. Complications are often severe and thus necessitate return to the operating room [11] . While IA is technically challenging and rarely performed, it preserves functional range of motion, does not impose weight restrictions and, while only a few reports of revision exist, can be converted successfully to TEA as is shown in this presented case [ 1 , 4 ].