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The surgical management of degenerative arthritis of the elbow includes open surgical debridement procedures, arthroscopy, total elbow arthroplasty, and ulnar nerve surgery.
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Options for the management of post-traumatic arthritis are the same as for degenerative arthritis and also include interposition arthroplasty.
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Primary surgical options for inflammatory arthritis of the elbow include synovectomy and total elbow arthroplasty.
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Rehabilitation is a standard postoperative component of all procedures and varies according to the specific procedure performed.
Elbow arthritis occurs as a result of progressive degenerative change within the elbow (osteoarthritis of the elbow), as a result of trauma (post-traumatic arthritis), or secondary to the development of inflammatory disease (most commonly, rheumatoid arthritis). It may also present in association with other conditions, such as psoriasis, hemophilia, and neuropathic pathologies, and as a final pathway after joint infection. With the exception of infection, which requires aggressive surgical intervention, there is a place for conservative treatment in early elbow arthritis. This may involve oral drug treatment, occasionally steroid injections, therapy, and, at times, orthotic use.
A number of surgical treatments are available when conservative measures are unsuccessful. Although any of these treatments may be indicated for an individual patient, the options can be divided broadly into those most suitable for degenerative and post-traumatic disorders and those more appropriate for inflammatory disease.
Surgical Management of Degenerative Arthritis
The surgical management of degenerative arthritis of the elbow can be divided into the following categories: open surgical debridement procedures, arthroscopy, total elbow arthroplasty, and ulnar nerve surgery. The choice as to which technique is most appropriate for the individual patient is determined by the severity of the disease and the experience of the surgeon.
Open Surgical Debridement Procedures
Outerbridge–Kashiwagi Method and Ulnohumeral Arthroplasty
Kashiwagi first reported an open debridement procedure that he attributed to Outerbridge and described as the Outerbridge–Kashiwagi method. Morrey later published a modification of this technique, which he called ulnohumeral arthroplasty. The procedure enables the removal of loose bodies, excision of osteophytes, and removal of the thickened olecranon fossa membrane.
The procedure is performed with the patient supine, a sandbag under the ipsilateral scapula, and the arm across the chest. With tourniquet control, a midline incision is made from the tip of the olecranon, extending proximally for 8 cm ( Fig. 110-1A ). The triceps is split in the line of its fibers and the posterior capsule exposed. This is opened, and loose bodies within the posterior compartment of the elbow are removed. Osteophytes at the tip of the olecranon and around the olecranon fossa are excised ( Fig. 110-1B ). The floor of the olecranon fossa is then fenestrated ( Fig. 110-1C ), with a bone trephine the size of which is determined by the diameter of the olecranon fossa. It is important that the fenestration does not compromise the medial or lateral columns because this may predispose the patient to fracture of the distal humerus ( Fig. 110-2 ). Usually, a trephine of 10 to 16 mm is appropriate.
Once a window into the anterior compartment of the elbow is produced, anterior loose bodies are displaced into the fenestration by elbow flexion and extension, enabling their removal. It is also possible to operate through the fenestration, excising osteophytes at the tip of the coronoid and partially releasing the tight anterior capsule.
The elbow is washed out and closed over a suction drain. Normally, the drain can be removed safely after a few hours. A firm, supportive wool and crepe bandage is applied.
Postoperative Rehabilitation
Postoperatively, I normally discharge patients within 24 hours. Before discharge, the dressing is reduced and the patient is instructed on progressive active elbow flexion and extension exercises. Progress is assessed at 10 to 14 days.
Morrey used a more aggressive postoperative regimen with continuous brachial plexus block for 3 days, together with continuous passive motion for 6 days. In addition, flexion and extension orthosis is used to maximize the operative gain in elbow movement.
Results of Surgery
Kashiwagi reported experience with this operation in 111 elbows. An improvement in spontaneous pain was noted in 88% of patients, with 67% showing benefit with respect to pain on movement. Seventy-six percent of patients gained flexion, and 55% gained extension. Mean follow-up was 54 months (range, 6 months–11 years). A later study by Minami et al. showed deterioration of the results with time. Symptoms were noted to recur in 20% of patients at 10 years, with recurrence of radiographic changes in up to 50% at 5 years.
At a mean follow-up of 33 months, using the Mayo Elbow Performance Score, Morrey found either excellent or good outcome in 12 of 15 patients (80%).
Phillips et al. reported long-term follow-up of patients undergoing this procedure. Twenty consecutive ulnohumeral arthroplasty procedures were reviewed at a mean follow-up of 75 months (range, 58–132 months). Excellent or good results were noted in 17 elbows (85%) using the Disability of the Arm, Shoulder, and Hand score and in 13 (65%) using the Mayo Elbow Performance Score. The benefits of surgery were maintained in 16 elbows, and of patients who were working at the time of surgery, 75% had returned to their original occupation. No correlation was found between radiologic recurrence of degenerative disease and the amount of fixed flexion deformity, the flexion arc, or the elbow score.
Good or excellent results were reported by Antuna et al. in 34 of 46 patients at an average of 80 months postoperatively. These authors advised decompression or mobilization of the ulnar nerve at the time of surgery in patients who had preoperative flexion of less than 100 degrees to avoid postoperative ulnar nerve complications.
Column Procedure
This technique is appropriate when elbow stiffness is the major presenting complaint. The patient usually notes a loss of extension, which may be painful, pain-free, or associated with discomfort at the extreme of movement. It can be used for stiffness associated with both primary and post-traumatic arthritis. It is normally performed via a lateral approach (lateral column), but a medial column procedure can also be undertaken, particularly if the ulnar nerve requires decompression or transposition.
The operation is undertaken under general anesthesia with the patient supine and with the arm across the chest. The surgical approach normally uses the proximal part of Kocher’s incision. However, if the elbow is very stiff, a posterior incision is preferred because this will enable medial and lateral skin flaps to be developed to gain access to both the lateral and medial sides of the joint. Whichever skin incision is used, the joint is normally opened initially on the lateral side, exposing the radiohumeral joint ( Fig. 110-3 ). Inspection of the capsule invariably shows it to be markedly thickened. The brachialis muscle is separated from the capsule with a periosteal elevator and the anterior capsule is excised. Often it is difficult to excise the anteromedial capsule with this approach, but it is normally possible to reach at least the level of the coronoid. Loose bodies within the anterior compartment and osteophytes are also removed at this stage. If restricted extension is still significant, a medial column approach can be performed to resect the anteromedial capsule.
Less frequently, loss of flexion is a concern and is usually caused by adhesions and scarring within the posterior compartment of the elbow joint. Treatment involves elevating the triceps, excising the posterior capsule, and removing posterior loose bodies and osteophytes.
Postoperative Rehabilitation
A brachial plexus block with in-dwelling catheter is particularly useful for postoperative analgesia and, if possible, should be continued for 2 to 3 days.
To maximize the improvement in range of movement achieved with surgery, the use of a continuous passive motion machine is helpful. The patient should be placed in the machine immediately after surgery, and the range of motion should be determined by what was obtained in the operating room. The patient must use the machine for at least 23 of the first 24 hours. Over the next few days, the patient is allowed increasing periods off the machine, with progressive active elbow exercises.
Results of Surgery
In 1990, Husband and Hastings reported their experience with a lateral approach to the elbow for the treatment of post-traumatic stiffness. At an average follow-up of 38 months, extension improved from an average preoperative flexion contracture of 45 degrees to 12 degrees postoperatively. In addition, maximal flexion increased from 116 degrees preoperatively to 129 degrees postoperatively. The average arc of motion increased by 46 degrees.
Mansat and Morrey, who introduced the term column procedure , reviewed 38 patients who had undergone surgery for elbow stiffness at a mean of 43 months postoperatively. Although in most cases the cause of stiffness was previous trauma, primary osteoarthritis was responsible for stiffness in seven patients. After surgery, the mean preoperative arc of flexion increased from 49 degrees to 94 degrees and there was a mean total gain in the arc of flexion–extension of 45 degrees. The column procedure was found to be associated with a low rate of complications.
Arthroscopy
Arthroscopy of the elbow can also be used for debriding the degenerate elbow, and with more extensive disease, osteocapsular arthroplasty can be performed. The technique requires appropriate training and can be technically demanding. In addition, it is potentially hazardous because of the close proximity of the major upper limb nerves to the entry portals and capsule.
The procedure is performed under tourniquet control with the patient in the supine, prone, or more commonly, lateral position. The surface anatomy of the elbow is identified and marked, and the joint is distended with saline via the posterolateral soft spot. Standard anterior and posterior arthroscopic portals are then created, with additional portals as required. The anterior compartment is usually examined first. Loose bodies are removed and osteophytes excised from the tip of the coronoid and anterior humerus. If loss of extension is a particular problem, the thickened anterior capsule can be excised, with care taken to avoid damage to the radial nerve as it lies anterior to the radial head.
The posterior compartment is then entered, loose bodies are removed, and osteophytes at the tip of the olecranon and around the olecranon fossa are excised. If loss of flexion is a particular problem, the posterior capsule is excised.
The medial and lateral gutters must be inspected because loose bodies may lodge at these sites. Great care is needed when working in the medial gutter because of the close proximity of the ulnar nerve.
If the patient has an arc of flexion and extension of less than 90 degrees before surgery, it is appropriate to consider preliminary release and anterior transposition of the ulnar nerve to avoid ulnar nerve complications secondary to improved elbow movement.
Postoperative Rehabilitation
Postoperative management involves the use of a nerve block to provide adequate analgesia, together with continuous passive motion to maximize the improvement in movement achieved surgically. For this approach to be beneficial, the patient must remain on the machine almost continuously during the first 24 hours. After this time, the patient is gradually weaned from the machine over the next 4 to 5 days. During this process, there is progressive introduction of active exercises supervised by the patient’s therapist.
Results of Surgery
In 1992, O’Driscoll and Morrey reported their experience with 24 elbow arthroscopic procedures with a mean follow-up of 34 months. They found that all patients with loose bodies within the elbow showed improvement after surgery. In addition, they noted that 30% of loose bodies were not seen on radiographs and 22% of patients had multiple loose bodies within the joint.
The risk of nerve damage after elbow arthroscopy was recorded by Ogilvie-Harris and Schemitsch. Of 34 patients who underwent elbow arthroscopy, 6% had transient nerve palsy, although there were no permanent injuries. A similar risk of nerve damage was noted by Rupp and Tempelhof, who reported an incidence of 5% transient radial nerve injuries.
Arthroscopic ulnohumeral arthroplasty was first described by Redden and Stanley. The technique allows removal of loose bodies, excision of osteophytes, and resection of the thickened olecranon fossa membrane. More recently, Krishnan et al. reported experience with this procedure in 11 consecutive patients who were younger than 50 years and had degenerative arthritis of the elbow. They found that the average preoperative arc of motion increased from 60 degrees to 133 degrees postoperatively.
Extensive debridement of the degenerate elbow with capsulectomy has been reported by Adams et al. Forty-two elbows with primary osteoarthritis were treated with arthroscopic osteophyte resection and capsulectomy and followed for a minimum of 2 years. Eighty-one percent had good or excellent results using the Mayo Elbow Performance Score. Complications were rare, with only one patient having heterotopic ossification and another having ulnar dysesthesia.
Total Elbow Arthroplasty
Because patients with primary degenerative arthritis are usually men 40 to 60 years with isolated elbow disease, it is uncommon to advise total elbow arthroplasty. This option is usually considered only for patients older than 65 years who have limited functional demands, who experience pain throughout the range of motion, or who have significantly reduced elbow movement and have not been helped by other treatment options.
Ulnar Nerve Surgery
Ulnar nerve surgery is indicated for patients with degenerative arthritis and isolated sensory or sensory and motor symptoms and those who have these symptoms as part of the disease process. The options for treatment include in situ decompression, superficial anterior transposition, intramuscular and submuscular anterior transposition, and medial epicondylectomy. Which option is preferred is normally determined by the personal choice of the surgeon.
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