Updated: 1/4/2022

Elbow Arthritis

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    • Elbow Arthritis is degenerative joint disease of the elbow that can be broken into three main types: osteoarthritis, post-traumatic arthritis and inflammatory arthritis.
    • Diagnosis can be made with plain radiographs of the elbow. 
    • Treatment can be nonoperative or operative depending on patient activity demands, severity of elbow pain and degree of elbow dysfunction.
  • Etiology
    • Osteoarthritis
      • epidemiology
        • incidence
          • clinically symptomatic primary osteoarthritis rare (2% prevalence)
        • demographics
          • men to women 4:1
          • middle-aged male laborers
          • can present from 20 to 70 years of age (average 50 years)
        • location
          • association with dominant hand
        • risk factors
          • strenuous manual labor
      • pathophysiology
        • etiologies include
          • primary arthritis
          • secondary causes
            • post-traumatic arthritis
            • osteochondritis dissecans
            • synovial osteochondromatosis
            • MUCL or ligamentous insufficiency, valgus extension overload
        • pathoanatomy
          • osteophytosis
          • capsular contracture
          • loose bodies
          • periarticular osteophytes block motion
          • preferentially involves radiocapitellar joint, sparing ulnohumeral articulation
    • Post-traumatic arthritis
      • epidemiology
        • second most common etiology of arthritis (rheumatoid historically the most common)
        • common after nonoperatively treated radial head fractures, elbow/fracture dislocations, and traumatic instability.
        • more common in younger patients compared to other etiologies (inflammatory and primary arthritis)
      • pathoanatomy
        • direct articular cartilage damage
        • surface incongruency alters load distribution across the bearing surface
        • may encompass entire joint or may be isolated to specific areas of the ulnohumeral and/or radiocapitellar articulartion
        • degenerative changes and early onset arthritis result as a consequence of the above
        • may be accompanied by stiffness, chronic instability, malunion, or nonunion
    • Inflammatory arthritis
      • epidemiology
        • rheumatoid arthritis
          • most common inflammatory arthropathy in adults
          • most prevalent elbow arthritis
          • elbow affected in 20% to 50%
          • causes progressive bone resorption and osteopenia
        • other causes
          • psoriatic arthritis
          • systemic lupus erythematosius
          • pigmented villonodular synovitis
      • pathophysiology
        • inflammation, chronic synovitis, ligament attenuation, periarticular osteopenia, capsular contracture
        • pathoanatomy
          • fixed flexion contracture
          • instability
          • ulnar or (less commonly) radial neuropathy
          • articular cartilage erosion
          • cyst formation
          • deformity
          • joint space loss
          • progressive instability
  • Anatomy
    • Primary stabilizing factors of elbow
      • anterior band MCL
        • anterior oblique fibers most important
        • stabilizes to both valgus and distraction forces
      • LCL
      • articular congruity between the olecranon, coronoid, and trochlea
    • Secondary stabilizers
      • radial head
        • most important
        • provides 30% of valgus stability
        • most important in 0-30° of flexion and pronation
      • capsule
        • primary restraint to distraction forces in full extension
      • anconeus, and lateral capsule
        • secondary stabilizer to varus force
    • Complete elbow anatomy and biomechanics
  • Presentation
    • Elbow osteoarthritis
      • symptoms
        • progressive pain, typically at end range of motion, not mid-range
        • loss of terminal extension
        • painful locking or catching of elbow
        • night pain unusual
      • physical exam
        • loss of elbow range of motion (terminal extension)
          • forearm rotation relatively preserved early
        • ulnar neuropathy in up to 50% of patients
    • Elbow inflammatory arthritis
      • symptoms
        • hand and wrist involvement usually precedes elbow
        • pain and loss of motion
      • physical exam
        • may have fixed flexion contracture
        • ligamentous incompetence can be seen
        • +/- ulnar neuropathy
        • evaluate cervical spine in all rheumatoid arthritis patients
  • Imaging
    • Radiographs
      • recommended views
        • ap/lateral of elbow, cervical radiographs recommended for RA patients prior to surgery
      • findings
        • elbow joint space narrowing
          • ulnohumeral joint space relatively preserved
        • osteophytes found at
          • coronoid process and fossa
          • radial head and fossa
          • olecranon tip and posteromedial olecranon fossa
        • loose bodies (underestimated on plain radiography)
        • periarticular erosions and cystic changes seen in RA
          • radiographic changes in RA graded by Larsen system
    • CT scan
      • useful for surgical planning
      • can help better define osteophytes and loose bodies
  • Treatment
    • Nonoperative
      • NSAIDS, cortisone injections, resting splints, and activity modification
        • indications
          • mild to moderate symptoms
    • Operative
      • arthroscopic debridement and capsular release
        • indications
          • mechanical symptoms from loose bodies
          • stiffness related to capsular contracture
          • stiffness related to bony block to motion
          • preferred in patients with >90° of motion
        • contraindications
          • Prior ulnar nerve transposition
          • severe contracture or arthrofibrosis
        • technique
          • removal of osteophytes and loose bodies (osteocapsular arthroplasty)
          • Capsular release
        • complications
          • neurologic injury
          • synovial fistula
          • recurrence of stiffness
      • ulnohumeral distraction interposition arthroplasty
        • indications
          • young, high demand patients with END STAGE arthritis (OA, RA, post-traumatic arthritis who would otherwise have received TEA if they were older) 
            • does not require lifting restrictions like TEA
          • elbow instability is a contraindication 
        • technique
          • can use
            • autogenous tensor fascia lata
            • achilles tendon allograft
        • complications
          • patients with severely limited preoperative motion (max extension > 60° and flexion < 100° are at risk for ulnar nerve dysfunction postoperatively
            • should undergo a concomitant ulnar nerve decompression/transposition
      • olecranon fossa debridement (Outerbridge-Kashiwagi procedure)
        • indications
          • younger patients with decreased ROM
        • technique
          • burr hole through olecranon fossa
            • removes osteophytes and arthritic bone
            • increases range of motion
          • be sure to decompress the ulnar nerve if there is an flexion contracture preoperatively
        • complications
          • failure to address anterior osteophytes or peripheral osteophytes on medial and lateral olecranon.
      • column procedure - medial or lateral open capsular release and bony resection
        • indications
          • extrinsic contracture of the elbow that causes functional loss of extension and/or flexion
          • most common technique; go medial if need to gain flexion by excising posterior band of MCL
      • total elbow arthroplasty
        • indications
          • older patients >65 years with severe elbow arthritis (Larsen stage 3-5)
          • complex distal humerus fracture in elderly with poor bone stock
          • distal humerus nonunion or malunion in elderly, lower demand
          • post-traumatic arthritis
        • contraindications
          • highly active patient <65
          • infection
          • Charcot joint
        • complications (as high as 43%)
          • infection
          • instability
          • loosening
          • wound healing problems
          • triceps insufficiency
          • ulnar neuropathy
  • Techniques
    • Total Elbow Arthroplasty
      • technique guide
    • Column procedure - limited lateral open capsular release and bony resection
      • approach
        • a limited lateral based incision along the lateral distal supracondylar ridge
      • arthrotomies
        • anterior arthrotomy accomplished through ECRL/Common extensor interval
          • stay anterior to LUCL to avoid iatrogenic injury
          • anterior capsule released and coronoid and coronoid fossae debrided
        • posterior arthrotomy accomplished by elevating triceps from the posterior aspect of the humerus
          • posterior capsule is released, the olecranon and olecranon fossae are debrided
  • Complications
    • Total complication rate may be as high as 43%
    • Infection and/or wound healing complications
      • Risk factors
        • prior elbow surgery
        • prior infection (esp. S. epidemidis)
        • psychiatric co-morbidity
        • rheumatoid arthritis
        • wound drainage
        • re-operation (any reason)
        • poor skin quality (e.g. long term steroid use)
      • Two-stage revision arthroplasty: poor survival
    • Injury to ulnar nerve
    • Triceps avulsion
    • Fracture
    • Aseptic loosening
      • Risk factors
        • linked implants
        • post-traumatic osteoarthritis
    • Implant failure (mechanical)
    • Instability
      • Risk factors
        • unlinked implants
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