Arthrodesis in a neuropathic elbow after posttubercular spine syrinx.

A 46-year-old man, who was left-hand dominant with known paraplegia due to tuberculosis spondylitis, presented with complaints of progressively increasing weakness and instability of the left upper limb for the past 2 years. The patient had difficulty using his left upper limb for activities of daily living such as eating, combing his hair, and maneuvering his wheelchair. On examination, the left elbow was swollen, but not warm, and was not tender. Range of motion was 25 to 100 , with palpable and audible crepitation. There was grade 3 weakness of the interosseous muscles and digital flexors of the ipsilateral hand. A sensory examination revealed sensory loss in the ulnar nerve distribution. Examination showed the median, radial, and musculocutaneous nerves were normal. Radiographs of the left elbow showed severe destruction of the distal humerus and proximal radioulnar joint with dislocation, and severe erosion into the intercondylar area left both condyles in an inverted U-shape. The proximal radioulnar joint was dislocated posterolaterally but no dissociation was noted in the proximal radioulnar bones. Diffuse soft-tissue swelling, especially in the posterior elbow and heterotopic ossification, was noted in the adjacent soft tissue (Figure 1). The patient gave a history of tuberculosis of the thoracic spine involving the second, third, and fourth thoracic vertebrae, which was treated with anterolateral decompression and antitubercular drugs 4 years previously. He remained paraplegic and wheelchairbound, but bladder and bowel functions were spared. Previous magnetic resonance imaging of his cervicothoracic spine revealed a cervicodorsal syrinx extending from C6 to T4, which was diagnosed 3 years previously (Figure 2). The patient had refused any surgical intervention for syrinx at that time. Results of blood investigations of patient were within normal limits. Computed tomography (CT)-guided aspiration of fluid from the elbow joint was investigated for gram stain and acid-fast bacilli stain as well as culture and polymerase chain reaction test for tuberculosis. All the results were negative. We discussed the treatment options, both conservative and surgical, including the high risks of failure in the latter with patient. Our patient insisted on having a stable elbow. Through a posterior approach, we performed ulnar nerve decompression and anterior transposition with arthrodesis of the elbow joint. Intraoperatively, the ulnar nerve was markedly displaced to the radial side (Figure 3). The radial head was excised. The articular margins of the humerus and ulna were freshened, and a prebent 12-hole locking plate (AO, Synthes Inc, West Chester, PA) was applied with the elbow in a functional position at 70 flexion. An anterior submuscular transposition of the ulnar nerve was performed. Results of gram stains, acid-fast bacilli stain, and culture of removed tissue were negative. Postoperatively, the limb was supported in an above elbow splint for 4 weeks. The patient was followed up at monthly *Reprint requests: Dr. Ajay Pal Singh, D-13, Residential Complex, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Dilshad Garden, New Delhi. E-mail address: [email protected] (A.P. Singh). J Shoulder Elbow Surg (2009) 18, e13-e16