IMPORTANT POINTS:
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Clinical consequences:
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The elbow is important in positioning the hand in space and stabilizing the upper extremity for both power and fine motor activities.
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Functional range of motion of the elbow for activities of daily living is a 100-degree flexion arc (30 to 130 degrees) and a rotational arc of 100 degrees (50 degrees supination and 50 degrees pronation).
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Flexion and supination are relatively more important.
CLINICAL/SURGICAL PEARLS:
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Nonsurgical management:
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Activity modification, nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs; methotrexate, gold, leflunomide, infliximab), steroids, splinting, ice/heat
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Operative treatment:
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Ulnohumeral debridement
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Open versus arthroscopic
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Synovectomy with or without radial head excision
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Distraction interposition arthroplasty
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Total elbow arthroplasty (TEA)
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Minimally constrained
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Semi-constrained
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Arthrodesis
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Osteoarticular allograft reconstruction
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CLINICAL/SURGICAL PITFALLS:
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Arthroscopy can be risky in improperly trained, inexperienced hands.
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Younger, active patients place intolerable stress on a TEA.
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Be wary of the soft tissue envelope.
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Ulnar neuritis is common after a motion restoring procedure and transposition should be considered.
INTRODUCTION
Patients with arthritis of the elbow most commonly complain of pain. They may also complain of stiffness, weakness, instability, or cosmetic deformity. Three primary types of arthritis affect the elbow: rheumatoid arthritis, posttraumatic arthritis, and primary osteoarthritis. Each of these occurs in a specific patient population and each has a characteristic clinical presentation.
Goals of treatment include alleviation of pain, increasing motion, and improving functionality. These are achieved by a combination of conservative measures followed by surgical intervention once less invasive measures have been exhausted. The choice of surgical intervention depends on multiple factors including type and extent of disease (i.e., bone loss, stability of the elbow), prior surgeries or infections, numerous patient factors (age, activity level, condition of ipsilateral shoulder and wrist, ability to comply with postoperative regimen), and surgeon preference. Advances in arthroscopy have expanded the surgical options available for treatment of all three primary patterns of arthritis, and numerous techniques and implants have been developed rendering elbow arthroplasty an effective and functional treatment for many patients. This chapter will provide a thorough overview of the surgical options available to the elbow surgeon for treatment of the arthritic elbow and the clinical indications for each. The subsequent chapters will discuss each surgical option in more detail, including technique, postoperative management, and results.
RHEUMATOID ARTHRITIS
The most common pattern of arthritis of the elbow is rheumatoid arthritis, an inflammatory disorder that affects women more commonly than men; it affects the elbow in 20% to 50% of patients. In only 5% of patients, elbow involvement is isolated and is occasionally the presenting symptom of systemic disease. The disease in up to 80% to 90% of patients affects the adjacent shoulder and wrist, respectively. Any treatment must account for the disability in other affected joints. Tissue integrity and quality must be considered when selecting a treatment option.
The pattern of involvement of the elbow is similar to that of other joints, with primary involvement of the ulnohumeral articulation. A characteristic more specific to rheumatoid arthritis is loss of bone stock, with or without associated destruction of the periarticular soft tissues, causing joint laxity that results in further destruction as a result of malalignment or subluxation. Eventually, the elbow may become flail, with excessive motion in the coronal plane.
Aggressive nonsurgical management, including systemic treatment with disease-modifying antirheumatic drugs (DMARDs), intraarticular corticosteroid injections, and physical therapy, can effectively treat many patients with early-stage disease. The most commonly applied classification system for rheumatoid involvement of the elbow, the Mayo Clinic Classification ( Table 18-1 ), considers the extent of synovitis, articular involvement, and deformity of the joint. Despite conservative management in many patients, inflammation and synovitis of the elbow joint over time can lead to changes including fixed joint contracture, ligamentous incompetence, instability, and cyst formation. Prolonged synovitis will ultimately lead to erosion of articular cartilage, along with subchondral cyst formation and eventually bone loss. The gradual destruction of the joint can cause significant pain and seriously limit upper-extremity function, necessitating consideration of surgical intervention. Early stages can be managed with synovectomy, either arthroscopic or open, for improvement of elbow mobility and for pain relief, whereas more progressed stages of rheumatoid arthritis are typically managed with total elbow arthroplasty (TEA).
| Grade | Description |
|---|---|
| I | No radiographic abnormalities except periarticular osteopenia with accompanying soft tissue swelling. Mild to moderate synovitis is generally present. |
| II | Mild to moderate joint space reduction with minimal or no architectural distortion. Recalcitrant synovitis that cannot be managed with nonsteroidal antiinflammatory medications alone. |
| III | Variable reduction in joint space with or without cyst formation. Architectural alteration, such as thinning of the olecranon or resorption of the trochlea or capitellum. Synovitis is variable and may be quiescent. |
| IV | Extensive articular damage with loss of subchondral bone and subluxation or ankylosis of the joint. Synovitis may be minimal. |
There is rarely an indication for an arthrodesis procedure in the patient with rheumatoid arthritis. An elbow arthrodesis would place an increased demand on the wrist and the shoulder. This is not well tolerated, especially in someone with polyarticular rheumatoid disease.
POSTTRAUMATIC OSTEOARTHRITIS
Posttraumatic osteoarthritis is the second most common type of elbow arthritis and affects young and middle-aged individuals most commonly. Damage to or loss of articular cartilage most frequently occurs in intraarticular elbow fractures, and secondary osteoarthrosis can result from this cartilage loss or from incongruency of the joint. Pain is the predominant symptom in the majority of patients and can be accompanied by stiffness, deformity, and bone loss ( Figs. 18-1 and 18-2 ).
Commonly, these patients have had multiple surgeries. Certain factors must be addressed when treating these patients:
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Skin condition and location of previous skin incisions
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Bony deformity, malunion, nonunion, and lack of bone stock
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Location of the ulnar nerve
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Competency of ligamentous restraints
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Existing hardware
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Heterotopic ossification
The primary goal of surgery for these patients is alleviation of pain, with secondary goals of improving function. Surgical options for patients with posttraumatic arthrosis of the elbow are numerous, including distraction interposition arthroplasty, total elbow replacement, arthrodesis, and osteoarticular allograft arthroplasty. Arthroscopy may be undertaken with care in select patients, but the risk of neurovascular injury in this setting must be seriously considered.
PRIMARY OSTEOARTHRITIS
Primary osteoarthritis of the elbow is relatively uncommon, comprising only 1% to 2% of patients presenting with elbow arthritis. It is much more commonly seen in males than females by a ratio of 4:1 and is typically diagnosed in middle-aged patients. Characteristic to this disease pattern is its prevalence in the dominant arm of an individual who repetitively uses his or her extremity for a particular occupation (i.e., a manual laborer, weightlifter, or throwing athlete). Although pain is the most frequent complaint in other types of arthropathies, loss of extension is the most common presenting symptom in patients with primary elbow osteoarthritis, with mild to moderate pain at terminal extension and, less frequently, terminal flexion. Carrying anything, such as a briefcase, with the elbow extended is painful. Pain in the midportion of the arc of motion is present only in the late stage. Flexion contractures of 30 degrees or more are commonly seen and may be associated with some loss of flexion. Radiographs typically reveal osteophytes on the olecranon and coronoid processes, filling in of the olecranon and coronoid fossae, and loose bodies. Involvement may include the radioulnar joint and the radiohumeral joint ( Fig. 18-3 ).
As with the other patterns of elbow arthritis, there are numerous surgical options once conservative management has failed. Prior to surgical intervention, the required demands to which the elbow will be subjected must be taken into consideration. Very aggressive osteophyte removal may destabilize the elbow in a demanding athlete, whereas a total elbow arthroplasty may loosen prematurely in a jackhammer operator.
Surgical treatments include arthroscopy (loose body removal, osteophyte resection, radial head contouring/resection, capsular release), the column procedure (open capsule release and osteophyte removal), ulnohumeral arthroplasty, and total elbow replacement. An ulnar nerve transposition is often indicated in the surgical treatment of osteoarthritis of the elbow. Symptoms of ulnar neuritis are common in this group of patients and postoperative gains in motion, especially when preoperative flexion is ≤100 degrees, may result in a traction-induced ulnar neuritis. This has been the case particularly with ulnohumeral arthroplasty. One outcomes study reported that 13 of 45 patients had ulnar nerve symptoms postoperatively. Six of these patients required additional surgery for ulnar nerve transposition ( Fig. 18-4 ).
Nonsurgical Treatment
Nonsurgical treatment options are similar to those of other joints affected by arthritis. Nonsteroidal antiinflammatory agents (NSAIDs) are used unless contraindicated by another medical condition or gastrointestinal side effects.
Rheumatoid arthritis is treated more effectively by DMARDs. Radioactive synovectomy is also minimally invasive and should probably be recommended as a more conservative treatment option to young patients with inflammatory arthritis or those with early inflammatory disease.
Physical therapy includes primarily pain control measures, such as avoidance of activities that place excessive stresses on the elbow, periods of rest, splinting, and application of heat and cold. Hinged braces that are lightweight and allow range of motion yet protect the elbow from varus–valgus stresses may minimize pain. Gentle exercises should be performed regularly to maintain mobility and strength in the muscles. Occupational therapy interventions with aids for activities of daily living are useful.
Surgical Treatment Options
Surgical treatment is offered once nonsurgical measures have failed to provide significant relief of symptoms. Surgical options include arthroscopic debridement (arthroscopic osteocapsular arthroplasty, loose body removal), arthroscopic synovectomy, open debridement (ulnohumeral arthroplasty), open synovectomy, distraction interpositional arthroplasty, total elbow arthroplasty, arthrodesis, total elbow allograft, and finally resection arthroplasty. The stage of disease, age of the patient, and the presence of other joint involvement dictate surgical treatment plans.
Arthroscopic Management
Indications for arthroscopic debridement and synovectomy are mild rheumatoid arthritis and primary osteoarthritis. Advances in elbow arthroscopy in recent years have allowed an increasing number of surgeons to use this tool for numerous conditions. It has been successfully used to treat specific stages and manifestations of rheumatoid, posttraumatic, and primary osteoarthritis of the elbow.
The main contraindication to arthroscopic treatment of arthritis is surgeon inexperience because of the risk of neurovascular injury. Elbows with greater deformity and stiffness have decreased capsular volume and are thus more difficult to treat with arthroscopy. Neurovascular structures in this situation are at greater risk of injury. The radial nerve lies either directly against, or within a few millimeters, of the anterolateral capsule, and the ulnar nerve is at risk lying adjacent to the posteromedial capsule. Compounding this issue is the fact that the diffuse synovitis often seen in the rheumatoid elbow can complicate navigation and landmark identification. It is thus advisable that surgeons with less experience with these techniques consider open techniques to manage these patients. A relative contraindication is older patients with lower demands who have significant articular damage and bony destruction—these patients are better candidates for total elbow arthroplasty.
Frequently cited as the most common indication for elbow arthroscopy, the arthroscopic removal of loose bodies has reported success rates of ≥90%. Loose bodies within the elbow are associated with several pathologic entities, including primary osteoarthritis, posttraumatic arthritis, and (less commonly) rheumatoid arthritis, in addition to other nonarthritic conditions (i.e., obsessive-compulsive disorder, synovial chondromatosis, osteochondritis dessicans). Patients most commonly present with symptoms such as locking, clicking, or catching. These mechanical symptoms can be accompanied by pain, swelling, and loss of motion. By removing these loose bodies, mechanical symptoms can be relieved and chondral injury is prevented.
Partial or complete synovectomy of the elbow can also be accomplished with arthroscopy, and the most common indications are pain, stiffness, and decreased function associated with rheumatoid arthritis that has failed medical management. Synovectomy and capsulotomy in the early stages of arthritis (elbows with some remaining articular cartilage and minimal bony destruction) can be an effective treatment for >10 years in the majority of patients. However, the maintenance of pain relief has been reported to diminish after 5 years. Although it has had the best results in these earlier stages, arthroscopic synovectomy and capsular release is also indicated in certain younger patients with greater chondral and bony destruction (Stages III and IV). These patients with more advanced disease will not have as predictably successful results, but the alternatives, including total elbow replacement, are not ideal either with concerns of prosthesis longevity. The results of arthroscopic synovectomy of 21 elbows after a mean followup of 97 months, the Mayo elbow performance score (MEPS) improved from a mean of 48.3 points preoperatively to 77.5 points postoperatively. It was noted that only patients with mild radiographic changes had favorable functional benefit at long-term followup. One reported an early success rate of 93% in a series of 14 patients who underwent arthroscopic synovectomies. Based on their results, the authors recommended arthroscopic synovectomy of the elbow in young patients (<50 years of age) who have failed 6 months of aggressive medical management and who have preoperative flexion arcs of >90 degrees and Grade I, II, or III radiographic changes. In another study by Nemoto and colleagues, arthroscopic synovectomy was performed on 11 patients with either Grades I to III or Grade IV arthritis. At a mean followup of 37 months, both groups of patients had improvement of elbow scores, including relief of pain and satisfactory functional outcomes. The authors recommend arthroscopic synovectomy in patients with rheumatoid arthritis who have painful, swollen elbows with Larsen Grade I to IV disease.
Tanaka and colleagues reported on the results of open and arthroscopic synovectomy in the treatment of the rheumatoid elbow. Fifty-eight elbows in 53 patients with rheumatoid arthritis and mild radiographic changes in the elbow (Larsen Grade II or less). Eleven (48%) of 23 elbows treated by arthroscopy and 16 (70%) of 23 elbows treated with an open synovectomy were mildly or not painful at the latest followup. This did not equate to a significant difference between the two in clinical results. In elbows with a preoperative arc of flexion of >90 degrees, arthroscopic synovectomy provided significantly better function than open surgery. An increase in the Larsen grade and recurrent synovitis was observed in both groups (6, arthroscopic; 3, open). Three elbows with a preoperative arc of flexion <90 degrees underwent a TEA for ankylosis following open synovectomy. They concluded that either open or arthroscopic synovectomy reliably relieved symptoms, especially in patients with a preoperative flexion arc of ≥90 degrees, in patients with early rheumatoid arthritis.
Arthroscopic debridement, also known as osteocapsular arthroplasty, offers an option for primary osteoarthritis of the elbow. The components of this procedure include removal of all loose bodies; debridement of the ulnohumeral articulation to remove all impinging osteophytes on the olecranon, coronoid, and trochlea; total synovectomy; and selective capsulectomy. Concomitant ulnar nerve transposition or decompression is often performed in patients with preexisting ulnar neuritis or in those patients with significant preoperative loss of flexion. This procedure is essentially designed to reshape the bones through debridement of the ulnohumeral joint and is primarily indicated for primary hypertrophic osteoarthritis in patients with painful end range of motion. It is also a useful tool for osteoarthritis secondary to osteochondritis dissecans and in some cases of posttraumatic arthritis or “burned-out” rheumatoid arthritis. Advantages of arthroscopic treatment include less postoperative pain and decreased intraoperative bleeding, which facilitates early gains in motion and recovery. This procedure is technically demanding, and injuries to the median, ulnar, and radial nerves have been reported following elbow arthroscopy. The use of retractors for improvement of visualization and prevention of neurovascular injury is an important technique to master.
Elbow arthroscopy can also be used to excise the radial head, although the indications for this procedure are much narrower. Its primary indication in arthritis is for posttraumatic radiocapitellar arthritis after radial head fractures. Its utility in rheumatoid and primary degenerative arthritis is more controversial. Resection of the radial head results in a modification of the force transmission across the ulnohumeral joint, which may propagate ulnohumeral arthritis. Kelly and colleagues presented a series of patients, at 5.6 years followup, with moderate to severe radiocapitellar involvement treated with an arthroscopic debridement without radial head excision. Eighty-four percent report a good to excellent outcome. It is reasonable to excise the radial head when the patient experiences pain, predominantly at the radiocapitellar articulation, that is severe enough to limit forearm rotation. With acute trauma to the radial head, excision is now rarely recommended secondary to concerns over ligamentous and longitudinal instability. In these cases, where the native radial head cannot be reconstructed, open radial head arthroplasty is currently the preferred treatment.
In a review of complications following elbow arthroscopy of 473 patients, 4 (0.8%) suffered a serious complication (a joint space infection). Minor complications occurred after 50 (11%) of the arthroscopic procedures. These complications included superficial infection after 33 procedures, persistent contracture of 20 degrees or less after 7, and 12 transient nerve palsies in 10 patients. The most significant risk factors for the development of a temporary nerve palsy were an underlying diagnosis of rheumatoid arthritis ( p <0.001) and a contracture ( p <0.05). There were no permanent neurovascular injuries, hematomas, or compartment syndromes.
Adams and colleagues recently reported on 41 patients treated by arthroscopic osteophyte resection and capsulectomy with more than 2 years of followup and an average of more than 3 years. Statistically significant improvements were cited in both pain ( p <0.0001) and motion ( p <0.0001). MEPS ( p <0.0001) increased from an average of 67.5 preoperatively to 84.4 postoperatively, with 81% having good to excellent results. The reported average postoperative flexion was 132 degrees (117.3 degrees preoperative), postoperative extension was 8.4 degrees (21.4 degrees preoperative), and postoperative supination was 78.6 degrees (70.7 degrees preoperative). Complications were rare (n = 2) and included heterotopic ossification and ulnar dysesthesias. Long-term results must be determined, but initially, arthroscopic osteocapsular debridement is safe and effective when performed by an experienced surgeon.
Cohen and colleagues compared the results of open versus arthroscopic debridement of the elbow at a mean 2.9 year followup. Eighteen patients were treated by the Outerbridge-Kashiwagi (open ulnohumeral arthroplasty) and 26 patients were treated by arthroscopic debridement and fenestration of the olecranon fossa. Both procedures were shown to be effective, with no major complications, in the treatment of primary osteoarthritis and posttraumatic arthritis. There was a trend for better pain relief in those patients treated by arthroscopic means, whereas those patients undergoing the open ulnohumeral arthroplasty achieved a significantly greater improvement in range of motion. No difference between the procedures in terms of patient-perceived overall effectiveness of the surgery was found.
Open Debridement (Ulnohumeral Arthroplasty)
Open debridement of the elbow, including capsule release, removal of loose bodies, decompression of impinging osteophytes, and trephination (18–20 mm) of the olecranon fossa is more recently known as an ulnohumeral arthroplasty. This procedure was originally described by Outerbridge and later popularized by Kashiwagi and is often referred to as the Outerbridge-Kashiwagi procedure. It is performed most commonly through a posterior incision. It has also been performed through a lateral column approach or with the arthroscope, as described previously. Other variations include resection versus preservation of the radial head and transposition of the ulnar nerve ( Figs. 18-5 and 18-6 ).
