I. Osteoarthritis
A. Epidemiology/overview
1. Symptomatic primary osteoarthritis (OA) of the elbow is relatively rare and affects 2% of the population.
2. The average age of presentation is 50 years (range, 20 to 70 years).
3. Men are affected more often than women (4:1 ratio).
4. Hand dominance and strenuous manual labor are associated with primary OA of the elbow.
5. Secondary causes include trauma, osteochondritis dissecans, synovial osteochondromatosis, and valgus extension overload.
B. Pathoanatomy
1. OA of the elbow is characterized by osteophyte formation, capsular contracture, and loose bodies (rather than by significant joint space narrowing).
2. Periarticular hypertrophic osteophytes act as a mechanical block at the end ranges of flexion and extension.
3. Rarely, advanced disease presents with joint space narrowing.
C. Evaluation
1. History
a. Patients typically present with loss of terminal extension and painful catching/clicking or locking of the elbow.
b. Pain is typically noted at the end ranges of motion and not through the midrange.
c. Night pain is not typical; if present, an inflammatory cause of the arthritis should be considered.
d. Determine the degree of disability caused by OA—Depends on the patient's vocation and physical disability.
2. Physical examination
a. Inspection—Check for prior surgical incisions and joint effusion at the lateral soft spot.
b. Assess range of motion—Pain is usually felt at the end ranges of flexion and extension rather than throughout the arc.
c. Forearm rotation is relatively preserved until later in the disease process.
d. Ulnar neuropathy is present in up to 50% of patients.
3. Imaging
a. Standard AP and lateral radiographs should be obtained (
Figure 1).
i. Radiographs typically show osteophyte formation at the coronoid process (anterior and medial), coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa.
ii. Joint spaces at the ulnohumeral and radio-capitellar joints are usually preserved.
iii. Loose bodies may be evident, and radiographs typically underestimate the number present.
b. CT may be useful for surgical planning; it allows for detailed assessment of osteophytes and the presence of loose bodies.
D. Treatment
1. Nonsurgical—Rest, nonsteroidal anti-inflammatory medication (NSAIDs), and activity modification are the mainstays of treatment.
2. Surgical—Indications
a. Failure to respond to nonsurgical interventions
b. Loss of motion that interferes with activities of daily living
c. Painful locking or catching of the elbow
3. Surgical procedures
a. Joint-sparing procedures such as debridement, excision of osteophytes, capsular release, and removal of loose bodies are preferred.
[Figure 1. Radiographs of an osteoarthritic elbow. AP view (A) shows peripheral osteophytes around the radial head (black arrow) and the tip of the olecranon (white arrow) with loss of normal contour of the olecranon fossa (broken line). Lateral view (B) shows osteophytes at the tip of the coronoid (black arrow), at the tip of the olecranon (white arrow), and at the radial and coronoid fossae (black arrowhead).]
b. Can be performed arthroscopically
c. Total elbow arthroplasty is rarely indicated, and it is not indicated for patients younger than age 65 years because of concerns about implant longevity.
d. Open procedures—Outerbridge-Kashiwagi arthroplasty (the classic open procedure)
i. Trephinate the olecranon fossa.
ii. Remove osteophytes.
iii. Limitations of the Outerbridge-Kashiwagi procedure are incomplete anterior release and incomplete osteophyte removal anteriorly.
iv. A column procedure or formal capsular release may be added to the Outerbridge-Kashiwagi procedure to limit exposure deficiencies; this procedure is known as ulnohumeral arthroplasty.
e. Arthroscopic procedures
i. Contraindications—Severe contracture, arthrofibrosis, previous elbow surgery, and ulnar nerve transposition are contraindications for arthroscopic repair.
ii. Osteocapsular arthroplasty refers to a more recently described arthroscopic technique for elbow joint debridement; it involves capsular release, loose body removal, and excision of osteophytes.
iii. Regardless of the type of arthroscopic procedure used, ulnar nerve decompression/transposition and release of the posterior bundle of the medial collateral ligament (MCL) should be considered for patients who have less than 90° to 100° of elbow flexion.
E. Complications
1. Persistent drainage (synovial fistula from arthroscopy)
2. Stiffness (heterotopic ossification)
3. Iatrogenic cartilage damage
4. Hematoma formation
5. Transient nerve palsies
6. Injury to cutaneous nerves or major nerves, including the radial, ulnar, and median
F. Pearls and pitfalls
1. During arthroscopic surgery, joint distention moves the capsule away from bone but the distance between the neurovascular structures and the capsule remain unchanged.
2. Neurovascular structures at risk during portal placement, debridement, and capsular release
a. Ulnar nerve (posteromedial)
b. Radial nerve (lies adjacent to anterolateral capsule)
3. The brachialis muscle protects the median nerve and brachial artery.
4. The olecranon fossa is an oval structure that is wider in the medial-to-lateral dimension.
G. Rehabilitation
1. Early active range of motion or continuous passive motion
2. Nighttime extension splinting
3. Prophylactic treatment for heterotopic ossification is not typically prescribed, but it may be used at the discretion of the surgeon.
4. A static, progressive splinting program may be implemented.
II. Inflammatory Arthritis
A. Epidemiology/overview
1. Rheumatoid arthritis (RA) is the most common inflammatory disease in adults.
2. In 20% to 50% of patients with RA, the elbow is affected.
3. Other less common inflammatory conditions include psoriasis, systemic lupus erythematosus, and pigmented villonodular synovitis.
B. Pathoanatomy
1. In RA, the disease typically presents initially as an intense synovitis that distends the joint and causes pain and loss of motion.
2. If the synovitis persists, secondary changes develop.
a. Fixed flexion contracture
b. Attenuation of the soft tissues and instability
c. Instability of the radial head develops through laxity of the annular ligament.
d. Ulnar neuropathy
e. Radial neuropathy has also been reported.
3. As RA progresses, the articular cartilage becomes involved, with destruction, erosion, and cyst formation seen. The end result is a severely deformed joint with loss of bone, loss of joint space, and progressive joint instability.
4. Loss of motion
5. Pain throughout range of motion
6. Ulnar neuropathy
[
Table 1. Larsen Grading System for RA]
C. Evaluation
1. Physical examination
a. Assess range of motion
b. Examine varus and valgus stability—RA often results in soft-tissue attenuation, which can lead to joint instability.
c. A thorough examination of the cervical spine is essential; many patients with RA have concomitant cervical spine abnormalities.
d. Ulnar neuropathy may or may not be present.
2. Imaging
a. AP and lateral plain radiographs should be obtained.
b. Patients scheduled for surgical procedures should have plain preoperative radiographs of the cervical spine.
D. Classification
1. RA is classified according to the Larsen grading system (Table 1), or the Mayo Clinic classification system (
Table 2).
2. The Larsen grading system is based on radiographic appearances (
Figure 2).
E. Treatment
1. Nonsurgical
a. Optimize medical management of systemic and joint pathology.
b. Resting splints during day and/or night may be useful.
c. Intra-articular steroid injections also may be useful for temporary pain relief.
2. Surgical
|
a. |
Indications i. Patients with Larsen stage 1 or 2 radiographs (Mayo grade I or II) are candidates for a synovectomy if their pain cannot be controlled with medical management. |
[Table 2. Mayo Clinic Classification of the Rheumatoid Elbow]
|
ii. |
In Larsen stages 3 through 5, surgical consideration should be geared toward total elbow arthroplasty ( Figure 3). |
|
|
iii. |
Rheumatoid arthritis is the primary indication for total elbow arthroplasty. |
|
|
b. |
The two basic types of elbow implants are linked and unlinked prostheses. i. Linked implants are joined together by a "sloppy hinge" to allow for some varus and valgus laxity during range of motion of the elbow; early loosening is a concern with these implants. ii. In unlinked implants, the humeral and ulnar components are not joined together and stability is provided by the surrounding soft tissues; instability is the main concern with this implant construct. iii. In patients with inflammatory arthritis, the soft tissues are often attenuated and there is a lower threshold for using a linked prosthesis. |
|
|
c. |
Contraindications for total elbow arthroplasty i. Active infection or Charcot joint is an absolute contraindication. ii. Relative contraindications include a lack of neurologic control of the extremity or a younger (age <65 years) active patient. However, total elbow arthroplasty is often performed in low-demand patients who are younger than age 65 years if symptoms are severe. |
|
[Figure 2. AP (A) and lateral (B) views of an elbow with Larsen stage 5 RA.]
[Figure 3. Radiographs of an elbow with Larsen stage 5 RA. AP (A) and lateral (B) preoperative views. AP (C) and lateral (D) views obtained 6 years postoperatively show a satisfactory result following total elbow replacement.]
3. Surgical procedures
a. Radial head excision is controversial.
b. Total elbow arthroplasty is indicated when loss of joint space and/or loss of normal joint architecture is present.
F. Complications
1. Complication rates as high as 43% have been reported for total elbow arthroplasty.
2. Arthroplasty complications include infection, instability, loosening, wound healing, ulnar neuropathy, and triceps insufficiency.
a. Risk factors for infection include previous surgery involving the elbow, a previous infection of the elbow, psychiatric illness, severe RA, wound drainage, or a reoperation on the elbow for any cause.
b. Patients with postoperative Staphylococcus epidermidis infections are at high risk for recurrent infections.
c. A two-stage revision is recommended when treating infected total elbow arthroplasties.
3. Instability is a complication of unlinked implants.
4. Loosening is a complication of linked implants.
5. Wound healing is an issue because skin is typically of poor quality and atrophic due to long-term corticosteroid use.
6. Triceps insufficiency can cause pain and weakness.
Bibliography
Aldridge JM III, Lightdale NR, Mallon WJ, Coonrad RW: Total elbow arthroplasty with the Coonrad/Coonrad-Morrey prosthesis: A 10- to 31-year survival analysis. J Bone Joint Surg Br 2006;88:509-514.
Antuna SA, Morrey BF, Adams RA, O'Driscoll SW: Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: Long-term outcome and complications. J Bone Joint Surg Am 2002;84:2168-2173.
Cheng SL, Morrey BF: Treatment of the mobile, painful arthritic elbow by distraction interposition arthroplasty. J Bone Joint Surg Br 2000;82:233-238.
Gramstad GD, Galatz LM: Management of elbow osteoarthritis. J Bone Joint Surg Am 2006;88:421-430.
Hildebrand KA, Patterson SD, Regan WD, MacDermid JC, King GJ: Functional outcome of semiconstrained total elbow arthroplasty. J Bone Joint Surg Am 2000;82:1379-1386.
Kauffman JI, Chen AL, Stuchin S, Di Cesare PE: Surgical management of the rheumatoid elbow. J Am Acad Orthop Surg 2003;11:100-108.
Little CP, Graham AJ, Carr AJ: Total elbow arthroplasty: A systematic review of the literature in the English language until the end of 2003. J Bone Joint Surg Br 2005;87:437-444.
Morrey BF: Complications of elbow replacement surgery, in Morrey BF (ed): The Elbow and its Disorders. Toronto, Canada, WB Saunders, 2002, pp 667-677.
Morrey BF: Nonreplacement reconstruction of the elbow joint, in Warner JJP (ed): Instructional Course Lectures: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 401-405.
Morrey BF, Adams RA: Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am 1992;74:479-490.
Norberg FB, Savoie FH III, Field LD: Arthroscopic treatment of arthritis of the elbow. Instr Course Lect 2000;49:247-253.
Ramsey ML: Elbow arthroscopy: Basic setup and treatment of arthritis. Instr Course Lect 2002;51:69-72.
Steinmann SP: Elbow arthritis, in Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 333-341.
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Top Testing Facts
Osteoarthritis
1. Symptomatic primary OA of the elbow is relatively rare; men are affected more often than women (4:1 ratio).
2. Hand dominance and strenuous manual labor are associated with primary OA of the elbow.
3. Patients typically present with loss of terminal extension and painful catching/clicking or locking of the elbow.
4. Radiographs typically show osteophyte formation at the coronoid process (anterior and medial), coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa. Joint spaces at the ulnohumeral and radiocapitellar joints are usually preserved.
5. Joint-sparing surgical procedures are preferred.
6. Nerves at risk during arthroscopy of the elbow include the radial, ulnar, and median.
7. Ulnar nerve decompression/transposition and release of the posterior bundle of the MCL should be considered for patients who have less than 90° to 100° of elbow flexion.
Inflammatory Arthritis
1. A thorough examination of the cervical spine is essential for all patients; many patients with RA have concomitant cervical spine abnormalities. Patients scheduled for surgical procedures should have plain preoperative radiographs of the cervical spine.
2. Patients with Larsen stage 1 or 2 radiographs (Mayo grade I or II) are candidates for a synovectomy if their pain cannot be controlled with medical management.
3. Total elbow arthroplasty is primarily indicated for patients with RA.
4. Instability is a complication of unlinked implants.
5. Loosening is a complication of linked implants.