The Problem
Post-traumatic elbow arthritis may be difficult to treat. Arthritic changes may result from residual instability which can lead to accelerated joint damage, chondral changes which occur at time of injury or joint incongruity following failure to obtain anatomic reduction.
Clinical Presentation
Patients are frequently asymptomatic despite radiographic evidence of arthritic changes. In those with symptoms, patients will often complain of a restricted arc of motion, particularly terminal extension. In cases of radial head fracture and arthritis secondary to same, pronosupination may be restricted. Depending upon the extent of joint changes, pain may be present at the end arcs of motion or throughout the arc of motion if there are widespread joint changes. Patients may complain of ulnar nerve symptoms.
Diagnostic Workup
Three view radiographs are obtained of the elbow. CT scans are very helpful to evaluate for arthritic changes or subtle joint incongruities. MRI or MR arthrogram may be used if osteochondral lesions or loose bodies are suspected.
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On physical examination, range of motion is documented of the affected side as well as the contralateral normal side. Pronosupination is assessed. Pain is assessed at end of the arc of motion as well as throughout the arc of motion. The status of the major peripheral nerves about the elbow, and the ulnar nerve in particular, are assessed. Specifically, subtle or overt signs of ulnar nerve compression are sought. The patient may have a Tinel’s at the cubital tunnel; a positive elbow flexion test or cubital tunnel compression test. Motor and sensory function is assessed.
Non–Operative Management
Some patients will find their symptoms manageable with non-operative means, such as activity modification, NSAIDs, and the occasional corticosteroid injection or with re-education or adjustment of expectations. Others will find their pain or functional limitations unacceptable.
Indications for Surgery
Indications for surgery include functional limitation of the elbow in arc of motion, pain recalcitrant to non-operative means and presence of pathology that will respond to surgical management. Patients with pain throughout the arc of motion may be more appropriate candidates for joint resurfacing procedures such as interposition arthroplasty or joint replacement. However, the literature suggests that outcomes following joint replacement arthroplasty for post-traumatic arthritis are less favorable than for other indications such as primary rheumatoid arthritis. This may be in part due to the often increased demands on the joints of those with post-traumatic arthritis relative to those with inflammatory arthritis. Those with pain at the end arc of motion or functional limitations in motion may be well suited to arthroscopic or open debridement of the elbow.
Surgical Technique
Patients may undergo arthroscopic or open debridement of the elbow. Patients who are candidates for these procedures are those with primarily pain at the end arcs of motion and/or a functional limitation in elbow motion. Patients should be educated that a small contracture (e.g., lacking less than 30 degrees short of full extension) may not be corrected with these procedures and expectations should be adjusted. Patients with pain throughout the arc of motion and or joint incongruity may not respond favorably to debridement procedures and may respond better to a resurfacing procedure such as an interposition arthroplasty or joint replacement arthroplasty. Patients with restricted pronosupination may be considered for removal of the radial head in an open or arthroscopic fashion; however, it should be recalled that pronosupination occurs at the proximal radioulnar joint, the distal radioulnar joint and along the axis of the forearm; thus longstanding stiffness in pronosupination may result in contractures of the forearm and wrist which may not respond to radial head resection alone.
For elbow arthroscopy, the patient is positioned in a lateral decubitus position on a bean-bag. General anesthesia is preferred. The arm is placed in an arm holder taking care to ensure that full flexion and extension are permitted, and that the elbow does not impinge on the body or the “down” arm. Bony and soft tissue landmarks are marked and the intended portal sites are marked. The tourniquet is elevated and the joint insufflated with 20-30 cc of saline. Arthroscopic portals are placed per the usual technique, with incision through the skin only and blunt dissection down to the joint. The anterolateral portal is usually the first portal made, just anterior and distal to the radiocapitellar joint. The anteromedial portal is made with an inside-out technique, usually 1 cm distal and anterior to the medial epicondyle. Viewing is facilitated by shaving any synovium or debris. Osteophytes are removed with a burr and joint flexion and extension is assessed for impinging osteophytes. Bony work is completed prior to addressing any capsular contracture. If the patient has capsular contracture, the capsule is released from the proximal joint at the humerus. Special precautions are required when considering shaving the capsule or performing a capsulectomy anterior to the radial head, as the radial nerve and PIN are vulnerable in this area.
Posteriorly, the portals are made at the direct posterior portal and the posterolateral portal. The posterior joint is a potential space and typically requires shaving to remove fat and fibrous tissue in the olecranon fossa to gain a visual field. Osteophytes are removed along the olecranon fossa, the posteromedial and posterolateral joint lines. Care is taken along the posteromedial joint when debriding and performing a capsular release given the proximity of the ulnar nerve. If ulnar nerve symptoms are present pre-operatively or a large restoration of joint motion is anticipated, ulnar nerve decompression should be considered, either via arthroscopic means or more commonly with a small open incision.
Open debridement is also an option and may be considered via a medial incision, a lateral incision, or both. Typically the patient is positioned supine with the arm either on an arm table or board, or draped over the chest. Tilting the table away from the surgeon can facilitate positioning. A sterile tourniquet and general anesthesia are preferred. On the medial side, the “over the top” approach is used. The ulnar nerve is identified and decompressed. The medial intermuscular septum is used as a key and is traced to the humerus. The anterior humerus is exposed and the flexor pronator group is divided in a z-lengthened fashion distally to expose the joint. Osteophytes are removed, and a capsulectomy performed. Posteriorly, the triceps is elevated and importantly the posterior medial capsule is released, including the posterior portion of the ulnar collateral ligament.
On the lateral side, the lateral musculature is elevated off the anterior humerus and the extensor digitorum comminus is split in line with its fibers, staying above the midline of the radial head. The anterior joint is exposed and osteophytes and capsule addressed. Posteriorly, the triceps is elevated and the posterior joint addressed.
Pearls and Pitfalls of Technique
It is important to understand patient expectations and the likelihood of the procedure to address the pathology present and if necessary adjust patient expectations or alter the procedure of choice. It is often difficult to achieve full arc of motion, and relatively small contractures may not respond to surgical management.
Ulnar neuropathy may complicate post-traumatic elbow stiffness and failure to address this may result in recurrent stiffness or worsening of ulnar nerve symptoms.
Patients who have pain throughout the arc of motion may also fail to respond to this procedure and may be better suited to a resurfacing type of procedure.
Potential Complications
Potential complications associated with these procedures include recurrent or residual symptoms and neurovascular injury.
Post–operative Rehabilitation
Following an initial period of splinting for 1-2 days depending on wound status, the patient initiates a supervised therapy program to achieve and maintain motion obtained intraoperatively. Splinting programs may be helpful to improve motion.
Outcomes/Evidence in the Literature
Outcomes following these procedures are dependent in large part upon the joint changes present and vary from patient to patient. Thus, outcomes series are difficult to interpret given the variability that exists in the patient population.
Ehsan, A, Huang, JI, Lyons, M, Hanel, DP. “Surgical management of posttraumatic elbow arthrofibrosis”. J Trauma Acute Care Surg. vol. 72. 2012. pp. 1399-403. (Following open debridement for post-traumatic stiffness, a gain in motion of approximately 60 degrees on average in the flexion extension arc. Complications were at an acceptable rate, with 8% developing recurrent heterotopic ossification, and 4 of 177 patients requiring repeat surgery for same.)
Ring, D, Adey, L, Zurakowski, D, Jupiter, JB. “Elbow capsulectomy for posttraumatic elbow stiffness”. J Hand Surg Am. vol. 31. 2006. pp. 1264-71. (In this series, 46 patients underwent elbow debridement for post-traumatic stiffness, and on average, restoration of 53 degrees in the flexion extension arc was noted, yielding a functional near 100 degree flexion extension arc in most patients.)
Kim, SJ, Shin, SJ. “Arthroscopic treatment for limitation of motion of the elbow”. Clin Orthop Relat Res. 2000. pp. 140-8. (In this series of arthroscopic debridement of the elbow 63 patients were followed for average 42.5 months. Patients improved following surgery until the 12 month postop mark; and achieved during the rehabilitation period, on average, the same motion obtained intraoperatively (121 versus 122 degrees). Patients with a shorter duration of symptoms pre-operatively (< 1 year) did better than those with longer symptoms (> 1 year).)
Summary
Treatment of post-traumatic elbow arthritis depends upon extent of changes and characteristics of pain and or functional deficits. Options include open or arthroscopic debridement or consideration of resurfacing type procedures for widespread joint changes. Treatment is tailored to patient needs and expectations and the pathology present.
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