Shoulder and Elbow
Evaluation and Management of Elbow Osteoarthritis
- Diagnostic Workup
Indications for Surgery
- Surgical Technique
Pearls and Pitfalls of Technique
- Post–operative Rehabilitation
Outcomes/Evidence in the Literature
The elbow is a modified hinge joint that consists of one synovial lining, 2 degrees of freedom (flexion-extension and pronation-supination), and three articulating surfaces (ulnotrochlear, radiocapitellar, and proximal radioulnar). While the elbow is a non-weightbearing joint, it withstands high stresses with daily activity all transmitted through a small surface area. With normal activities of daily living the elbow experiences loads of approximate 1x body weight, this increases to 3x body weight with strenuous lifting and up to 6x body weight during throwing and pounding activities. Elbow arthritis can be caused by rheumatoid arthritis, post-traumatic osteoarthritis (PTOA), primary osteoarthritis, septic arthritis, crystalline arthropathy, hemophilia, osteochondritis dessicans, synovial chondromatosis, and degenerative changes from valgus extension overload (seen in overhead throwing athletes). Primary elbow osteoarthritis represents 1-2% of all elbow arthritis, with the majority of cases of symptomatic elbow arthritis having PTOA and rheumatoid arthritis as etiologies.
Three main pathologic processes are involved in elbow osteoarthritis: Loose bodies form from fragmentation of cartilage, osteophyte formation leads to impingement and progressive joint capsular contracture ensues. Advanced arthritis leads to destruction of the joint space.
At the present time the optimal treatment of symptomatic elbow osteoarthritis remains controversial.
Primary elbow osteoarthritis affects men four times as often as women, with a mean age of onset of 50 years. It predominantly affects manual laborers, workers that use pneumatic tools, overhead throwing athletes, weight lifters, and those who rely on wheelchairs or crutches.
Post-traumatic elbow osteoarthritis may occur with patients of any gender or age, but most commonly occurs in young males. The risk of developing osteoarthritis after injury is dependent on the injury pattern and the amount of energy that caused the injury (e.g., distal humerus, radial head, and proximal ulna fractures, and fracture/dislocations of the elbow).
In early osteoarthritis, patients complain of elbow pain at the extremes of flexion and extension. At maximum extension, degenerative osteophytes on the olecranon impinge with osteophytes present on the olecranon fossal. At maximum flexion, osteophytes of the trochlea and coronoid cause impingement. Coupled with pain, elbow stiffness and restricted range of motion are due to these impinging osteophytes and the capsular contracture that commonly develops during the disease process. Mechanical symptoms such as catching and locking may be present due to the presence of intra-articular loose bodies. In addition to pain with range of motion, patients with elbow arthritis often report an inability to carry heavy objects.
As the disease progresses, patients report pain and crepitus throughout their restricted arc of motion. Stiffness becomes a common complaint with associated functional limitations.
Cubital tunnel syndrome is commonly associated with elbow osteoarthritis with symptoms including paresthesias, weakness, and decreased grip strength.
Physical examination begins with inspection including assessing whether there is any gross deformity of the elbow, any evidence of prior surgical scars or regions of fibrosis. Palpation of all bony landmarks (e.g., olecranon tip, radial head) is performed looking for tenderness at these sites. The presence of a joint effusion is evaluated by palpating the "soft spot" (the center of triangle formed by the radial head, lateral epicondyle, and proximal olecranon) looking for fullness or bounce back. Range of motion is then evaluated with comparisons made to the contralateral side. Whether or not the patient is capable of functional elbow range (30-130° flexion/extension arc with 50 degrees of pronation and 50 degrees of supination) should be determined. The elbow range of motion should be measured with a hand held goniometer. Commonly, crepitus is noted to be present with range of motion in the setting of advanced disease. The character of the endpoints of motion should be determined -- hard versus soft, painful versus painless. Next, the elbow is assessed for varus, valgus and rotatory stability with collateral ligament testing performed at 30 degrees of elbow flexion.
A complete neurovascular examination of the affected extremity including sensation, strength testing and a Tinel's test over the cubital tunnel should be performed.
Plain radiographs are used to evaluate the extent of degenerative changes present in the arthritic elbow. The series includes an anteroposterior view of the elbow, a lateral view of the elbow shot in 90°of flexion, a Greenspan view of the radial head and an oblique view of the radiocapitellar joint. Plain radiographs will typically demonstrate osteophytes present about the olecranon, in the olecranon fossa, about the coranoid and the coronoid fosa. Loose bodies may be seen within the joint space. The extent of elbow arthritis can be assessed by noting the degree of joint space narrowing present in the ulnohumeral, radiocapitellar and proximal radioulnar joints. In the setting of post-traumatic elbow osteoarthritis the radiographic appearance may be more variable. While joint space narrowing is still the primary finding, joint subluxation may be present and there may be evidence of malunion, nonunion or heterotopic ossification in addition to hardware from previous surgery.
Special diagnostic tests
If any suspicion of joint infection exists, the patient should undergo full infection workup including an aspiration of any effusion present for cultures and cell count. If a baseline neuropathy exists, a neurology consultation including EMG/NCV should be obtained to document baseline nerve function. Advanced imaging including CT - (particularly 3D CT) can be used to evaluate for loose bodies, impinging osteophytes, significant bone deformity, and cases of heterotopic ossification. CT arthrography may sometimes be indicated to evaluate the extent of cartilage lesions present and MRI can provide additional information about the extent of synovitis in addition to the identification of any comorbid ligament injury that may be present.
Non-operative management of symptomatic elbow arthritis includes long term activity modifications, NSAIDs or acetaminophen for pain control, intra-articular steroid injections to reduce inflammation and physical therapy to preserve elbow motion and strength. Specific joint protection rehabilitation programs instruct the patient on techniques to reduce elbow stresses during activities of daily living. Viscosupplementation has been attempted but this treatment remains controversial as while it may or may not offer some short term effect, no long term benefit has been demonstrated.
Indications for Surgery
When non-operative management fails to effectively reduce the patient's pain and improve their function, surgical intervention is considered. Many surgical options have been described with the patient's age, activity level, type and severity of arthritis directing the surgical approach. For moderate degenerative changes can consider arthroscopic or open debridement. For more severe degenerative changes, options include interpositional arthroplasty and total elbow arthroplasty.
Ulnohumeral arthroplasty, open osteocapsular debridement and/or arthroscopic debridement are recommended for patients with impingement symptoms and pain at the extremes of motion and those with mild to moderate degenerative changes associated with restricted range of motion short of the functional range. Patients with primarily mechanical symptoms in the setting of intra-articular loose bodies are good candidates for arthroscopic loose body removal and debridement.
Interpositional arthroplasty is considered for patients less than 60 years old with painful and restricted range of motion and low functional demands. The goal is symptom and functional improvement while delaying the need for total elbow arthroplasty.
Total elbow arthroplasty is considered the treatment of choice for patients older than 60-65 years old, with low functional demands whose complaints are painful and restricted range of motion in the setting of significant degenerative changes.
Open elbow debridement
The lateral approach allows access to all three joint articulations, but requires a second incision to address the ulnar nerve. General or regional anesthesias used. The patient is positioned supine with the extremity on an arm board. An extended Kocher incision is made from the lateral humeral supracondylar ridge and passing distally in the interval between anconeus and extensor carpi ulnaris (ECU). The anconeus is retracted and the dissection continues by mobilizing the triceps from the posterior humerus. The ulnohumeral joint is identified and the olecranon fossa is cleared of fibrous tissue. The tip of the olecranon and all osteophytes present are removed. The radiocapitellar joint is inspected and osteophytes are removed; the posterior capsule is released. The dissection continues anteriorly by releasing the brachioradialis and extensor carpi radialis longus (ECRL) from the supracondylar ridge. The brachialis is mobilized off the humerus and dissection between the ECRL and extensor carpi radialis brevis (ECRB) continues to expose the anterior capsule. The capsule is excised to the medial side of the joint. The radial and coronoid fossae are cleared of fibrous tissue and osteophytes. If radiocapitellar degeneration is present, the radial head may be resected. Loose bodies are removed if present. The wound is closed layer by layer and the skin is closed with 3-0 nylon.
The medial approach allows access to the posteromedial olecranon osteophytes and also the ulnar nerve, but does not allow access to the radial head and capitellum. General or regional anesthesias used. The patient is positioned supine with the affected extremity placed on a hand table. An incision is placed from the distal border of the pronator teres along the ulnar nerve, continuing proximally to the posterior aspect of the arm. During dissection, the medial antebrachial cutaneous nerve is preserved over the flexor carpi ulnaris. The ulnar nerve is released and transposed. The posteromedial joint is exposed by excising the posterior-oblique bundle of the medial collateral ligament (MCL). Medial osteophytes are removed. The posterior compartment is reached through the interval between the triceps and the posterior humerus. The posterior capsule is excised to visualize the olecranon and remove osteophytes. The anterior compartment is visualized by retracting the common flexor group. The medial half of the common flexors and the anterior capsule are incised to expose the anterior elbow and the radial fossa osteophytes are removed. The wound is closed layer by layer and the skin is closed with 3-0 nylon.
The posterior approach is used for debridement of olecranon and olecranon fossa osteophytes, but does not allow access to the ulnar nerve or radiocapitellar joint. General or regional anesthesia can be used. The patient is positioned in the lateral decubitus position and the extremity is draped over a post. A posterior, triceps splitting approach is utilized to expose the olecranon fossa. Regions of bony impingement are removed and the wound is closed with 3-0 nylon
Ulnohumeral arthroplasty (Outerbridge Kashiwagi - OK procedure)
This procedure is reserved for patients with pain at extremes of range of motion due to impingement and includes an open debridement with trephination of the olecranon fossa. Note that this procedure is more successful in situations of impingement due to a central impinging osteophyte and less successful if the impingement is due to impinging osteophytes along the posteromedial and posterolateral aspect of the posterior compartment. Given the advances made with elbow arthroscopic techniques, the Outerbridge Kashiwagi procedure has become less popular.
This procedure is done through a posterior approach, but can also be performed arthroscopically or by a lateral approach. General or regional anesthesia can be used. The patient is positioned in a lateral decubitus position with the affected arm placed over a post. A 10cm posterior longitudinal incision extends from 6cm proximal to the olecranon tip distally. The triceps fascia is identified and the triceps tendon is split and spread to visualize the posterior elbow joint. A capsulotomy is performed and olecranon osteophytes are removed. Loose bodies are removed as they are encountered. A window through the olecranon fossa is drilled with a 1.5cm surgical dowel that is angled anteriorly and cephalad by 20 degrees to access the anterior elbow. A curettage is used to smooth the edges. The elbow is flexed maximally to visualize the coronoid; osteophytes are removed from the coronoid. If there are radiocapitellar symptoms, the radial head may be removed. If ulnar nerve symptoms are present, the ulnar nerve is transpositioned. The triceps tendon is repaired and the wound is closed layer by layer. The skin is closed using 3-0 nylon.
Arthroscopic elbow debridement
Arthroscopic debridement offers a minimally invasive approach to elbow debridement with the potential for rapid rehabilitation, improved elbow motion, and pain relief. Moreover, the ability to perform a dynamic arthroscopy in order to visualize the precise location of impingement is a significant advantage compared to the traditional open approaches.
General anesthesia is used. The patient is positioned in either the supine position with an arm holder or lateral decubitus position on a bean bag with the elbow in an arm holder. Surgeon preference dictates starting the arthroscopy in either the posterior compartment or anterior compartment. 20ml of normal saline is injected into the joint using an 18 gauge needle through the "soft spot." With the elbow in flexion, a high anteromedial portal is placed by incising 2cm of skin proximal to the medial epicondyle and anterior to the medial intermuscular septum. The trochar is placed just anterior to the distal humerus and directed distally. Insert a 30 degree, 4.0mm arthroscope into the joint and position between the radial head and capitellum in the anterior compartment. The anterolateral portal is then created using a spinal needle placed 2cm anterior to the lateral epicondyle. Scapel is used for the skin only and blunt penetration into the joint is performed. A 3.5mm shaver is inserted allowing for a capsulectomy and synovectomy of the anterior structures to be performed and osteophytes are debrided off the coronoid and coronoid fossa.
If radiocapitellar disease is present, then radial head resection may be performed arthroscopically using a motorized burr. Care needs to be taken to avoid suction of the capsule into the burr. The radial head resection may also be performed through an open posterolateral approach. Loose bodies are removed as they are encountered. For entry into the posterior compartment, a posterolateral portal at the posterolateral corner of the olecranon is used. A direct posterior portal is placed through the triceps, 2cm from the proximal-most palpable tip of the olecranon. Osteophytes are removed from the olecranon tip and olecranon fossa. Care must be taken not to injure the ulnar nerve.
If flexion contracture exists, the posterolateral and posteromedial capsule as well as the ulnar nerve may need to be released. Given the proximity of the ulnar nerve, consideration should be given to perform the posteromedial capsular release using a mini-open incision in combination with an in situ ulnar nerve release. The portals are closed with 3-0 nylon and a sterile dressing is applied.
This procedure aims to create a painless pseudoarthrosis by resecting the articular surface and replacing it with a graft (e.g., autogenous dermis, fascia lata, or allogenic Achilles tendon). An interpositional arthroplasty aims to relieve pain while preserving bone stock for total elbow arthroplasty in the future. However, the surgical dissection required for this procedure may be as invasive, if not more so, than what is required for a total elbow arthroplasty.
General or regional anesthesias used. The patient is placed supine with the extremity on a hand table. A 10cm posterior longitudinal incision is made to expose the triceps fascia. The ulnar nerve is identified medially, transposed, and protected. The deep surface of the triceps tendon is freed which allows access to the posterior distal humerus and also facilitates joint dislocation. Laterally, the interval between the anconeus and ECU are developed and the lateral soft tissues are elevated. Capsular adhesions and heterotopic bone is removed. The elbow is dislocated and the varticular surface is evaluated. If the radial head is affected, then the radial head is resected. A Rongeur and high speed burr are used to contour the olecranon, capitellum, and trochlea until the surfaces are smooth. The selected graft material is prepared; if both trochlea and capitellum are to be covered then the graft should be 8-9cm x 20-25cm. If only the trochlea will be covered then the graft should be 6cm x 12cm.
Three anteroposterior and one medial-lateral drill tunnels are created in the distal humerus. The graft is folded lengthwise and sutured into place through the drill tunnels. The elbow is reduced and stability is checked by taking the elbow through an arc of motion. If unstable, collateral ligaments can be reconstructed. A hinged external fixator is applied to allow healing and ensure elbow stability.
Total elbow arthroplasty
This procedure is avoided in young, active populations due to high complication rates and limited prosthesis survivorship. Implants can be constrained, unconstrained, or semi-constrained. Semi-constrained implants are most commonly used due to stability and reduced rates of aseptic loosening.
General anesthesia is used. The patient is placed in the lateral decubitus position on a bean bag and the affected extremity is draped over a post. A 15cm posterior longitudinal incision is placed halfway between the medial epicondyle and the olecranon tip. The triceps fascia and the medial aspect of the distal triceps is exposed. The ulnar nerve is identified and transposed. The triceps are reflected to expose the posterior elbow and the joint is dislocated.
Dull tip Hohmann retractors are placed medially and laterally and a saw is used to resect the distal half of the condyles. An awl is used to establish the medullary canal of the humerus and a rasp is used to size for an appropriate size implant component. The brachialis is elevated to allow the humeral flange of the prosthesis to fit properly. The tip of the olecranon is cut parallel to the plane of the anterior aspect of the ulna. Access to the ulnar medullary canal is obtained by removing the base of the coronoid. The radial head is excised at the junction of the head and neck. Trial components are inserted and connected with a pin. Elbow range of motion and stability are assessed. The medullary canals are thoroughly irrigated and the bone ends are dried. Cement is prepared and placed. The ulnar and humeral components are inserted and the elbow is extended to fully seat the components. The wound is closed layer by layer and the triceps tendon is repaired. The wound is closed with 3-0 nylon.
Salvage procedures are used when other procedures are exhausted.
Elbow arthrodesis is sometimes discussed as an option for failed total elbow arthroplasty, but this is challenging since there often is missing bone stock as well as potentially significant shortening required.
Pearls and Pitfalls of Technique
Patients with a history of elbow trauma or previous ulnar nerve transposition are at higher risk of neurovascular injury.
During arthroscopy, if the anterior compartment will be entered first, the elbow capsule should be distended with saline prior to portal placement to increase the distance from the bone to the nerve distance. This is not necessary if arthroscopy will begin in the posterior compartment.
Patients with preoperative ulnar nerve symptoms or less than 90 degrees of flexion routinely need ulnar nerve transposition.
Common complications regardless of surgical approach include infection, heterotopic ossification, post-operative elbow stiffness and ulnar neuropathy.
Potential complications of open elbow debridement include fracture, hematoma, median nerve and brachial artery injury (at risk when an anterior elbow dissection is performed), posterior interosseous nerve injury (at risk if the dissection proceeds distal to the radiocapitellar joint).
Potential complications of elbow arthroscopy include ulnar, median, superficial radial, posterior interosseus, medial antebrachial neuropathies, brachial artery injury, compartment syndrome.
Potential complications of interpositional arthoplasty include elbow instability, graft failure and triceps rupture.
Potential complications of total elbow arthroplasty include wound healing issues, aseptic loosening, catastrophic implant failure, periprosthetic fracture, instability, triceps weakness, and implant wear.
Postoperatively, a posterior long arm splint is applied with the forearm in neutral rotation and 20 degree flexion for 1 week. After splint removal, active range of motion is initiated. Some may use dynamic splinting or continuous passive motion (CPM) to maximize range of motion.
Postoperatively, the patient is immobilized in a hinged ex-fix until wound healing is complete. After wound healing, the patient should undergo supervised active, active assisted, and passive range of motion exercises for the first month postoperatively. The external fixator is removed at 6 weeks and physical therapy (PT) or dynamic splinting continues for 3 months to ensure maximum range of motion.
Total elbow arthroplasty
Postoperatively, a long arm splint is applied with the elbow at 20 degrees flexion and neutral forearm rotation. The splint is maintained for 10-14 days with the elbow in a sling. After the splint is removed, gentle passive range of motion is initiated; however, flexion greater than 90 degrees is avoided until triceps healing is evident. Permanently, the patient must avoid lifting greater than 10lbs and avoid repetitive lifting more than 2lbs.
Outcomes/Evidence in the Literature
Lim, TK. "Arthroscopic debridement for primary osteoarthritis of the elbow: analysis of preoperative factors affecting outcome". J Shoulder Elbow Surg. vol. 23. 2014. pp. 1381-1387.(The study investigated 43 patients who underwent arthroscopic debridement for primary elbow osteoarthritis. They found that arthroscopic debridement provides satisfactory pain relief, improved elbow motion, and good functional outcomes.)
Barthel, PY. "Is total elbow arthroplasty indicated in the treatment of traumatic sequelae? 19 cases of Coonrad-Morrey(®) reviewed at a mean follow-up of 5.2 years". Orthop Traumatol Surg Res. vol. 100. 2014. pp. 113-118.(This retrospective study evaluated 19 patients (mean age 60 years old) who underwent total elbow arthroplasty as treatment for post-traumatic osteoarthritis or post-traumatic non-union of a distal humerus fracture. They report at 5.5 years follow up good to excellent outcomes.)
Maclean, SM. "Medium-term results of arthroscopic debridement and capsulectomy for the treatment of elbow osteoarthritis". J Shoulder Elbow Surg. vol. 22. 2013. pp. 653-657.(The study offers a retrospective review of 20 patients who underwent arthroscopic debridement and capsulectomy of the elbow for primary osteoarthritis. They found improved outcomes for most patients after the procedure.)
Sears, BW. "Post-traumatic elbow arthritis in the young adult: evaluation and management". J Am Acad Orthop Surg. vol. 20. 2012. pp. 704-714.(This article reviews the treatment of post-traumatic elbow arthritis in young adults.)
Yan, H. "Arthroscopic debridement of osteoarthritic elbow in professional athletes". Chin Med J. vol. 124. 2011. pp. 4223-4228.(This study reports the clinical outcomes of 35 professional athletes (ages 7-34 years of age) with elbow arthritis treated with arthroscopic debridement. The authors found short term relief of pain and improved range of motion.)
Naqui, SZ. "Early results of the Acclaim total elbow replacement in patients with primary osteoarthritis". J Bone Joint Surg Br. vol. 92. 2010. pp. 668-671.(This retrospective study evaluates total elbow replacement in 11 patients with primary elbow osteoarthritis. They report pain and functional improvement in their patients with low loosening rates.)
Adams, JE. "Osteoarthritis of the elbow: results of arthroscopic osteophyte resection and capsulectomy". J Shoulder Elbow Surg. vol. 17. 2008. pp. 126-131.(This is a retrospective review of 41 patients with primary elbow arthritis who underwent arthroscopic osteophye resection and capsulectomy with 2 year follow-up. They report improved mean flexion, supination, and outcome scores.)
Gramstad, GD. "Management of elbow osteoarthritis". J Bone Joint Surg Am. vol. 88. 2006. pp. 421-430.(This article reviews the literature regarding the management of primary elbow osteoarthritis.)
Tashjian, RZ. "Functional outcomes and general health status after ulnohumeral arthroplasty for primary degenerative arthritis of the elbow". J Shoulder Elbow Surg. vol. 15. 2006. pp. 357-366.(This study evaluates outcome measures for 17 patients that underwent ulnohumeral arthroplasty. The found improved mean elbow flexion and forearm rotation and outcome scores.)
van Brakel, RW. "Intra-articular injection of hyaluronic acid is not effective for the treatment of post-traumatic osteoarthritis of the elbow". Arthroscopy. vol. 22. 2006. pp. 1199-1203.(This study investigated the effect of intra-articular hyaluronic acid injection in 18 patients with post-traumatic osteoarthritis. They report minimal short term pain improvement and limited improvement in functional impairment.)
Cohen, AP. "Treatment of osteoarthritis of the elbow: a comparison of open and arthroscopic debridement". Arthroscopy. vol. 16. 2000. pp. 701-706.(This non-randomized control trial evaluates open and arthroscopic debridement of elbows with osteoarthritis. This study recommends arthroscopic debridement for patients with a primary complaint of elbow pain and an open debridement in patients with a primary complaint of restricted motion.)
Osteoarthritis of the elbow is characterized by elbow stiffness, impingement pain, and restricted range of motion. When nonoperative management fails to reduce pain and improve function, surgical options including open debridement, arthroscopic debridement, ulnohumeral arthroplasty, interpositional arthroplasty and total elbow replacement are considered. The patient's age, activity level, disease severity, and treatment history guides the definitive management for patients with elbow osteoarthritis.
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