Bassem Elhassan
Scott P. Steinmann
Definition
Degenerative primary arthritis of the elbow is an uncommon problem.1 It occurs in less than 2% of the population and principally affects the dominant extremity in middle-age manual laborers. It has also been reported in people who require continuous use of a wheelchair or crutches, athletes, and in patients with a history of osteochondritis dissecans of the elbow. It has different pathologic changes than the age-related changes of the distal humerus and the radiohumeral joint.
Because of the younger age and increased activity levels of patients with primary osteoarthritis of the elbow, the treatment options are more limited and the role of total elbow arthroplasty is less defined in this population of patients.
Pathology
Histopathologic Changes in Elbow Osteoarthritis
The degenerative changes of the elbow joint are usually more advanced in the radiohumeral joint, where bare bone is often in wide contact and the capitellum appears to have been shaved obliquely (Fig. 60-1). This is owing to the high axial, shearing, and rotational stresses at this articulation, which result in marked erosion of the capitellum and callus hypertrophy formation in a skirtlike pattern on the radial neck.
The ulnohumeral joint is usually less involved in the beginning of the disease process and becomes more pronounced with more advanced disease. The central aspect of the ulnohumeral joint is characteristically spared. The anterior and posterior involvement of this joint is usually manifested by fibrosis of the anterior capsule in the form of cordlike band and hypertrophy of the olecranon.
Osteophyte growths are seen over the olecranon (especially medially), the coronoid process, and the coronoid fossa. These changes in the radiohumeral and ulnohumeral joints lead to the loss and fragmentation of the cartilaginous joint surfaces with distortion, cyst formation, and bone sclerosis. Kashiwagi noted that the early stage of the disease is characterized by small, round bony protuberances that progress into various shapes of osteophytes and bony sclerosis with more advanced cases.
Clinical Presentation
Despite considerable radiographic severity, many patients with osteoarthritis of the elbow report minimal symptoms. This is partly related to the fact that the elbow is a slight weight-bearing joint compared with the lower extremity joints.
Mechanical symptoms of locking and catching caused by intra-articular loose bodies, pain at the end points of the arc of motion (flexion or extension), and progressive loss of range of motion are characteristic manifestations of osteoarthritis of the elbow. In athletes who are required to hyperextend their elbows, pain can be significant and limits their performance.
With more progressive disease, the patients may have pain with forearm rotation and throughout the range of elbow motion. This could lead to disability in this patient population as well as in the older laborers who extensively use their upper extremity.
Medial joint pain in patients with advanced osteoarthritis of the elbow might be the first manifestation of ulnar neuropathy. It is reported that ≤20% of patients with primary osteoarthritis of the elbow have some degree of ulnar neuropathy. The proximity of the ulnar nerve to the arthritic posteromedial aspect of the ulnohumeral joint makes it susceptible to impingement. The expansion of the capsule as a result of synovitis and the presence of osteophytes in that area of the joint result in direct compression and ischemia of the ulnar nerve. Acute onset of
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cubital tunnel syndrome in patients with osteoarthritis of the elbow might be also the first manifestation of medial elbow ganglion.
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Figure 60-1 A lateral view of the right elbow, showing advanced osteoarthritis specifically involving the radiocapitellar joint. Notice the formation of osteophytes anteriorly and posteriorly. |
Imaging and other Diagnostic Studies
The characteristic radiographic features seen on the anteroposterior and lateral radiographs of the elbow include radiocapitellar narrowing, ossification, and osteophyte formation in the olecranon fossa in almost all patients with osteoarthritis of the elbow. Loose bodies and fluffy densities might be observed filling the coronoid and olecranon fossae (Fig. 60-2).
Computer tomography (CT) also helps in delineating the detailed structural anatomy of the articular surface of the elbow with an accurate determination of the locations of the osteophytes and loose bodies. When contemplating surgical treatment of the osteoarthritic elbow, a CT is quite helpful for determining which osteophytes need to be removed. Radiographs do not allow for accurate visualization of all osteophytes.
Nonoperative Management
Because of the young age of the patients with primary osteoarthritis of the elbow, most of these patients tend to be active and involved in manual labor work, which will place a great demand on any kind of prosthetic replacement. All limited operative debridement options should be exhausted before contemplating elbow replacement in this group of patients.
Early in the course of the disease, treatment by nonsurgical measures should be followed. This consists of activity modification, physical therapy, anti-inflammatory medications, and possibly steroid injection. As in other joints arthritis, if there is no improvement with these symptomatic measures, operative management is warranted.
Surgical Management
Elbow arthroscopy is a good option for removal of intra-articular loose bodies and is effective in relieving the patient's mechanical symptoms of catching and locking. Elbow arthroscopy has proved quite effective in removing osteophytes and releasing tight areas of capsule in the arthritic elbow. Surgeons with significant experience in elbow arthroscopy can remove all restricted capsule and reach all areas of the anterior and posterior elbow joint and areas of impinging osteophytes. To release a similar amount of the elbow joint with an open approach would require a wide exposure.
Techniques
Kashiwagi popularized the open elbow decompression described by Outerbridge, which consisted of decompression of the ulnohumeral joint with resection of the coronoid and olecranon osteophytes and fenestration of the distal part of the humerus. A disadvantage of this technique is the difficulty in exposing and excising the osteophytes in the radial head fossa.
Savoie et al. reported good results with extensive arthroscopic debridement involving capsular release, fenestration of the distal part of the humerus, and removal of osteophytes. Also, Morrey reported good results with open ulnohumeral arthroplasty, a variation of the original technique in which a trephine is used to remove the osteophytes encroaching on the olecranon and coronoid fossae.
If the above options fail to relieve the patient symptoms, then total elbow arthroplasty (TEA) may cautiously be considered as the next alternative of treatment. Most studies in the literature reporting on total elbow arthroplasty involve large numbers of patients, mostly with rheumatoid arthritis or other inflammatory pathologies, but very few patients with primary osteoarthritis. This makes it difficult to make accurate conclusions on the value of this treatment option for this population of patients. There are few studies in the English literature reporting specifically on the
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outcome and complications of TEA as a treatment option for patients with primary osteoarthritis of the elbow.
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Figure 60-2 An anterior-posterior and lateral view of a right osteoarthritic elbow showing narrowing of the joint line and subchondral sclerosis, with formation of osteophytes in the coronoid, capitellar, and olecranon fossae. |
Kozak et al. reported on the Mayo clinic experience. Over a 13-year period, only 5 out of 493 patients (<1%) who underwent TEA had the procedure performed for primary osteoarthritis of the elbow. The Coonrad-Morrey prosthesis (Zimmer, Warsaw, IN) cemented semiconstrained prosthesis was used in three patients, and the Pritchard elbow-resurfacing system (ERS) (De Puy, Warsaw, IN) cemented unconstrained prosthesis was used in the other two patients. The average age of the patients was 67 years, and a follow-up ranged from 37 to 121 months. Two minor and four major complications were reported in four elbows, two of which required revision. This rate of complications according to the authors is much higher than the rate of complication reported in TEA performed for other reasons in the same institution during the same period of time, including revision TEA, posttraumatic arthritis, nonunion of distal humerus, and rheumatoid arthritis.
Espag et al. reported on 11 Souter-Strathclyde cemented unlinked primary total elbow arthroplasties in 10 patients with osteoarthritis of the elbow. The diagnosis was primary osteoarthritis of the elbow in nine patients and posttraumatic osteoarthritis in two patients. The average age of the patients was 66 years, with a mean follow-up of 68 months. Only one patient required revision after 97 months for ulnar component loosening. All patients reported good symptomatic relief of pain and a significant increase in range of motion, and all patients considered the procedure to be successful.
The authors compared these results with the result of Souter-Strathclyde total elbow arthroplasty used in patients with rheumatoid arthritis. The revision rate in their series (9%) performed for ulnar component loosening compares favorably with the revision rate with the rheumatoid patients (5% to 21%), in which the main indications for revision included dislocation and perioperative fracture. The authors attributed the decrease in the incidence of perioperative and postoperative fracture to the good amount of bone stock in patients with primary osteoarthritis of the elbow that makes the risk of fracture very minimal.
As evident from this review, the outcome studies of TEA in patients with primary osteoarthritis of the elbow are very limited. The above-mentioned studies included small numbers of patients, and no final recommendation could be drawn at this time.
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It is hoped that a greater understanding of elbow anatomy and kinematics will lead to advances in prosthetic design and surgical technique. The newer anatomic unlinked implants may improve the outcome of elbow replacement in younger patients. More outcome studies are needed on these implants or any other modern implants before openly recommending elbow replacement in younger active patients with primary osteoarthritis of the elbow.
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