INTRODUCTION

As discussed in Chapter 76, primary osteoarthritis of the elbow is an uncommon lesion that affects fewer than 2% of the population.¹⁸ In recent years, an increased incidence or increased recognition, or both, resulted in a greater experience that has offered an opportunity for a more discrete treatment plan based on the specific features of the presentation. These consist both of subjective reports and objective findings. Based on the features of the presentation, three discrete surgical options have emerged: loose body removal, débridement, and joint replacement. All can be appropriate depending on patient symptoms, expectations and surgeon expertise.^2,⁸

The primary report may be catching from a loose body, loss of extension, or pain on terminal extension from osteolysis and capsular contracture, or ulnar nerve symptoms tend to occur later in the process.

The radiographic features are motonous and generally correlate reasonably well with the patient’s symptoms. The primary pathology includes maintenance of joint space in the presence of osteophyte formation in the olecranon, olecranon fossa, coronoid, and coronoid fossa.^9,¹¹ Secondary changes include osteophytes at the margin of the radial head and loose bodies. Occasionally the radiohumeral joint is selectively involved. As implied, all of these characteristics are readily discerned by the plane radiograph. Computed tomography (CT) or magnetic resonance imaging (MRI) scans are not needed or indicated to diagnose or treat this patient.

Selecting the appropriate procedure depends on the clinical and radiographic presentation (Table 60-1). In the early stages, most patients have mild pain and are treated by nonoperative means,¹³ such as with anti-inflammatory medication and activity modification. Occasionally, removal of loose bodies or débridement with removal of prominent osteophytes is necessary. This can be achieved by arthrotomy or today, most commonly, by arthroscopy. Formal and more aggressive open débridement procedures are employed for extensive involvement, especially with ulnar nerve symptoms.

TABLE 60-1 Treatment Options Based on Presenting Symptoms and Radiographic Features

Presentation
Clinical	Radiographic	Procedure
1. Extension loss, mild pain	Small olecranon spur	None—activity; medication
2. As for 1, limits activity	Larger olecranon/coronoid spurs	Column, arthroscopic débridement
3. Locks, catches	Loose body	Arthroscopic removal
4. Pain with flexion/extension, motion restricted	Osteophyte: foramina, coronoid/olecranon	Column, arthroscopy, ulnohumeral arthroplasty
5. As for 1-4, with ulnar nerve symptoms	As above	Ulnohumeral arthroplasty, nerve decompression
6. Pain arc, high-grade motion loss	Extensive osteophytic changes, joint narrowing, capsular contracture	Age <65, interposition arthroplasty; age >65, semiconstrained total elbow arthroplasty
7. Symptoms localized to radial/humeral joint	Radiohumeral arthritis	Radial head replacement, possible capitellar replacement.

Total elbow arthroplasty is considered an option only after débridement and loose body excision has failed ³ or is not appropriate and for older patients. However, some surgeons believe that replacement rarely, if ever, is indicated for advanced primary osteoarthritis of the elbow,¹⁹ particularly if using unlinked implants.^4,^6,⁷ Still, there are no published reports or detailed clinical data to substantiate any of these positions. Readers may be surprised to learn that, until 1998, there was no information in the literature documenting either technical difficulties or the functional outcome of total joint replacement for primary arthritis of the elbow.¹⁰ Since the report in 1998, only a single additional report of a small series of replacements for degenerative disease has appeared.⁵ For this reason, we are reassessing our experience.

INDICATIONS

Total elbow arthroplasty is rarely indicated for primary osteoarthritis of the elbow, because it typically affects relatively young, active men. For them, several effective options are available to address the various elements of the complaint: locking, stiffness, and impingement pain (see Table 60-1).¹⁴ The specific but relative indications for joint replacement for primary arthritis include age older than 65, if possible, and a patient who does not need or expect to make extensive use of the extremity. The other options noted earlier must have failed or have been deemed inappropriate for the lesion. Most important, patients who have pain throughout the arc of motion, especially in the functional range, are the best candidates for joint replacement. Radiographs often show extensive heterotopic changes about the elbow joint (Fig. 60-1). High-grade stiffness in older patients is also a potential setting for joint replacement. The limited arc and hypertrophic changes pose technical challenges to successful replacement.