Bassem Elhassan, Matthew L. Ramsey, and Scott P. Steinmann
DEFINITION
Primary degenerative arthritis of the elbow is an uncommon problem.1
It occurs in less than 2% of the population29 and principally affects the dominant extremity in middle-aged manual laborers.1,3,17,23,29
The disorder predominates in men and is rarely seen in women, with an incidence of 4 to 5:1.8
The dominant extremity is involved in 80% to 90% of symptomatic patients. Bilateral involvement of the elbow is noted in 25% to 60% of patients.6
It has also been reported in people who require continuous use of a wheelchair or crutches, in athletes, and in patients with a history of osteochondritis dissecans of the elbow.21,25
The pattern of pathologic changes in primary degenerative arthritis is different than the age-related changes of the distal humerus and the radiohumeral joint.6,26
The current understanding of the disease process in primary degenerative arthritis has led to treatment algorithms designed to address the pathologic process short of joint replacement.
The role of total elbow arthroplasty (TEA) for patients with primary degenerative arthritis of the elbow is limited, in large part because of the younger age and increased activity levels of patients with this condition.
PATHOGENESIS
The exact pathogenesis of primary osteoarthritis of the elbow is still unknown. It is generally believed that overuse plays a key role in the onset of the disease process. However, younger patients with this disease often have predisposing conditions such as osteochondritis dissecans.11
The degenerative changes of the elbow joint are usually more advanced in the radiohumeral joint, where bare bone is often in wide contact, and the capitellum appears to have been shaved obliquely (FIG 1).6
This is due to the high axial, shearing, and rotational stresses at this articulation, which result in marked erosion of the capitellum and hypertrophic callus formation in a skirt-like pattern on the radial neck.32
The ulnohumeral joint is usually less involved in the beginning of the disease process, but involvement becomes more pronounced with more advanced disease.21
The central aspect of the ulnohumeral joint is characteristically spared. The anterior and posterior involvement of this joint is usually manifested by fibrosis of the anterior capsule in the form of a cord-like band and hypertrophy of the olecranon.
Osteophytes are seen over the olecranon, especially medially, the coronoid process, and the coronoid fossa.
These changes in the radiohumeral and ulnohumeral joints lead to the loss and fragmentation of the cartilaginous joint surfaces with distortion, cyst formation, and bone sclerosis.2
Kashiwagi9 noted that the early stage of the disease is characterized by small, round bony protuberances; the early stage progresses into various shapes of osteophytes and bony sclerosis with more advanced cases.
Suvarna and Stanley30 reported on the progressive fibrosis of the local marrow, increased thickness of all the bony components of the olecranon fossa, and increases in anterior and posterior fibrous tissues.
PATIENT HISTORYAND PHYSICAL FINDINGS
Despite considerable radiographic severity, many patients with osteoarthritis of the elbow report minimal symptoms.11
Trauma rarely underlies the onset of degenerative arthritis. However, trivial injury often brings the problem to the patient’s attention.
Characteristic manifestations of primary degenerative arthritis of the elbow are well described.22,24 These include:
Progressive loss of motion
FIG 1 • Lateral view of right elbow, showing advanced osteoarthritis specifically involving the radiocapitellar joint. Notice osteophyte formation anteriorly and posteriorly.
Mechanical symptoms of locking and catching caused by intra-articular loose bodies (occurs in about 10% of patients)9
Pain at the extremes of motion due to mechanical impingement of osteophytes (pain occurs most frequently at terminal extension, although about 50% of patients also have pain during terminal flexion)
Pain throughout the arc of motion indicates significant involvement of the ulnohumeral joint; this typically occurs late in the disease process.
Ulnar neuropath.
Medial joint pain in patients with advanced osteoarthritis of the elbow might be the first manifestation of ulnar neuropathy.
Up to 20% of patients with primary osteoarthritis of the elbow have some degree of ulnar neuropathy.1
The proximity of the ulnar nerve to the arthritic posteromedial aspect of the ulnohumeral joint makes it susceptible to impingement.
The expansion of the capsule as a result of synovitis and the presence of osteophytes in that area of the joint result in direct compression and ischemia of the ulnar nerve.
Acute onset of cubital tunnel syndrome in patients with osteoarthritis of the elbow might be also the first manifestation of a medial elbow ganglion.10
Radiocapitellar symptoms: With more progressive disease, the patients may have pain with forearm rotation and throughout the range of elbow motion. This could lead to disability in this patient population as well in the older laborers who extensively use their upper extremity.6,16,33
PHYSICAL FINDINGS
Physical examination findings depend on the extent of the patient’s disease.
Range of motio.
The flexion-extension arc will demonstrate loss of extension greater than flexion and will average about 30 to 120 degrees.
The midrange of the flexion–extension arc is typically pain-free in the early stages of the disease.
A painful midrange of motion and crepitus indicate more extensive involvement of the ulnohumeral joint.
The arc of pronation–supination is rarely affected early in the disease process. Involvement of the proximal radioulnar and radiohumeral joint later in the disease process may limit forearm rotation.
Forced motion at the extremes of flexion and extension will often cause pain, particularly in extension.
Ulnar nerve symptoms need to be thoroughly evaluated. Symptoms of ulnar neuropathy associated with primary degenerative arthritis of the elbow include:
Decreased sensation and weakness
Positive Tinel sign at the cubital tunnel
Positive elbow hyperflexion test
IMAGING AND OTHER DIAGNOSTIC STUDIES
Some characteristic radiographic features are seen on the anteroposterior and lateral radiographs of the elbow:
Radiocapitellar narrowing (noted in 25% to 50% of patients)
Ossification and osteophyte formation in the olecranon fossa in almost all patients with osteoarthritis of the elbow15,21
Osteophyte formation of the coronoid and olecranon processes
Loose bodies and fluffy densities might be observed filling the coronoid and olecranon fossae (FIG 2A,B).
Radiographs do not allow for accurate visualization of all osteophytes.
A cubital tunnel view is obtained if there is ulnar nerve irritation to look for impinging osteophytes or loose bodies.4,6,7
Computed tomography (CT) helps in delineating the detailed structural anatomy of the articular surface of the elbow with an accurate determination of the locations of the osteophytes and loose bodies (FIG 2C).
When contemplating surgical treatment of the osteoarthritic elbow, a CT is quite helpful for determining which osteophytes need to be removed.
FIG 2 • A,B. Anteroposterior and lateral views of a right osteoarthritic elbow show narrowing of the joint line and subchondral sclerosis, with formation of osteophytes in the coronoid, capitellar, and olecranon fossae. C. Computed tomography of the elbow demonstrating marginal osteophytes on the ulna and olecranon fossa.
Three-dimensional reconstructions provide additional detail on osteophytic deformity and facilitate preoperative planning of removal.
MRI does not provide any useful information in primary osteoarthritis of the elbow and is rarely indicated.
NONOPERATIVE MANAGEMENT
Because of their young age, most patients with primary osteoarthritis of the elbow tend to be active and involved in manual labor, which will place a great demand on any kind of prosthetic replacement.
Early in the course of the disease, treatment by nonsurgical measures should be followed.21
This consists of activity modification, physical therapy, anti-inflammatory medications, and possibly steroid injection or visco-supplementation.13
SURGICAL MANAGEMENT
Indications
If nonoperative treatment fails to improve symptoms, surgery may be indicated.
Several surgical options exist for the management of primary degenerative arthritis of the elbow. Surgery is directed toward addressing the pathology contributing to the predominant complaints of the patient.
The surgical techniques depend on.
Degree of osteophyte formation
Degree and direction of motion loss
Associated loose bodies
Associated ulnar nerve symptoms
Degree of ulnohumeral involvement resulting in pain through the midrange of motion
Arthroscopic Débridement
Arthroscopic management of degenerative arthritis of the elbow is discussed in detail in Chapter SM-22.
In general, arthroscopic débridement for degenerative arthritis of the elbow can be performed for moderate to severe disease when there are no midrange symptoms, indicating limited involvement of the ulnohumeral joint.
Advantages of arthroscopy include the ability to visualize the entire joint and limited morbidity from surgery.
Savoie et al reported good results with extensive arthroscopic débridement involving capsular release, fenestration of the distal part of the humerus, and removal of osteophytes.28
Disadvantages of arthroscopy include potential neurovascular injury and difficulty assessing the normal anatomic relationships, resulting in inadequate débridement, compared with open débridement and release.
Contraindications to arthroscopic treatment include altered neurovascular anatomy, limited surgical expertise, and advanced involvement of the ulnohumeral joint.
Open Débridement
Open débridement can be performed for all patients with primary degenerative arthritis of the elbow.
Open joint débridement should be considered in patients with advanced disease or when the treating surgeon has limited experience with arthroscopic techniques.
Options for open débridement of the elbow include:
Outerbridge-Kashiwagi arthroplasty (see Chap. SE-42)
Lateral column approach for débridement (see Chap. SE-43)
Medial over-the-top approach for débridement (see Chap. SE-44)
Total Elbow Arthroplasty
TEA for the treatment of primary osteoarthritis of the elbow is performed sparingly in carefully selected patients. In general, the patient population with primary degenerative arthritis of the elbow includes relatively young men who are physically active in their occupation and want to remain so. TEA is contraindicated in high-demand patients.
The indications for TEA for primary degenerative arthritis of the elbow include patients older than 65 years with low physical demands and a painful arc of motion. These patients should have attempted and failed all other appropriate treatment options.
Implant Choices
Unlinked (resurfacing) and linked (semiconstrained) designs may be appropriate in patients with primary degenerative arthritis of the elbow.
The current literature supports the use of linked implant designs for primary degenerative arthritis. However, osteoarthritis may be the best indication for the use of an unlinked implant.
Linked implants
Current linked designs with a semiconstrained, loosehinged articulation allow varying degrees of varus–valgus motion and rotational laxity (FIG 3A).
Muscle activation about the elbow protects against excessive loading, thereby reducing aseptic loosening.
FIG 3 • A. Linked implant with a semiconstrained, loose-hinged articulation. Linkable implants can be used unlinked (B), or the ulnohumeral articulation can be captured, converting the unlinked implant to a linked implant (C). (Courtesy of Zimmer, Warsaw, IN.)
Unlinked implant.
Anatomic requirements for the use of unlinked implants include:
Competence of the medial and lateral collateral ligaments
Minimal deformity of the subchondral architecture
Integrity of the medial and lateral supracondylar columns
Maintenance of the collateral ligaments and surrounding muscles helps absorb forces across the elbow, thereby reducing stress on the bone–cement interface. This has the theoretical, but unproven, advantage of offloading stresses on the implant.
Some authors believe that this potential advantage may allow this implant type to be used in a higher-demand patient population. However, this potential advantage is yet unproven. Therefore, the indications for total elbow replacement are still limited in this patient population to patients willing to adopt low physical demands.
The major complication of unlinked implants is instability.
If an unlinked implant is considered in this patient population, the ability to convert to a linked replacement (linkable) has obvious advantages.
Linkable implant.
These devices permit implantation in an unlinked fashion, taking advantage of the benefits of an unlinked design (FIG 3B).
The ulnohumeral articulation can be captured, thereby converting the unlinked implant to a linked implant by placing an ulnar cap on the ulnar component (FIG 3C). This can be performed at the time of implantation of the unlinked implant if stability cannot be established or at a point distant to the initial implantation if instability becomes an issue.
Patient Positioning
The patient is positioned supine on the operating room table with a bump under the ipsilateral scapula. The arm is positioned across the chest and supported on a bolster (FIG 4).
A tourniquet is applied to the arm. The use of a sterile tourniquet increases the “zone of sterility” and allows removal for more proximal exposure if needed.
Approach
The surgical technique for linked arthroplasty is discussed in other chapters. Please refer to these chapters for the specific technical details of implantation of a linked, semiconstrained implant. This chapter will discuss an unlinked total elbow system, which can be converted to a linked implant if required for stability.
FIG 4 • Patient positioning with the arm across the chest supported on a bolster.
TECHNIQUES
SURGICAL EXPOSURE
A straight posterior, midline incision placed just off the medial tip of the olecranon is used (TECH FIG 1).
Full-thickness flaps are elevated. The extent of flap elevation is based on how the triceps is to be managed surgically.
The ulnar nerve is identified, protected with help of a Penrose drain, and transposed anteriorly.
TECH FIG 1 • Straight posterior midline skin incision is placed off the medial aspect of the olecranon. (Courtesy of Tornier, Inc., Edina, MN.)
TRICEPS MANAGEMENT
Surgical management of the triceps is a matter of surgeon preference. The general methods of triceps management are triceps-sparing, triceps-reflecting, and triceps-splitting approaches.
Triceps-sparing approaches leave the triceps attached to the tip of the olecranon. The advantage of this type of approach is that it prevents triceps weakness postoperatively, but it sacrifices surgical exposure.
Triceps-reflecting approaches subperiosteally elevate the triceps from its attachment on the ulna; it must be carefully reattached and protected postoperatively. However, surgical exposure is facilitated with these approaches.
Triceps-splitting approaches violate the attachment of the triceps to the ulna yet provide the advantages of improved visualization of the joint.
Triceps-splitting approac.
A triceps-splitting approach is performed by completing a midline split in the triceps muscle and tendon, which is carried distally onto the ulna along the subcutaneous border of the ulna between the anconeus and the flexor carpi ulnaris (TECH FIG 2A).
The medial triceps is elevated in continuity with the flexor carpi ulnaris while the lateral triceps is elevated in continuity with the anconeus. Care must be taken when elevating the medial triceps flap. The medial triceps attachment to the triceps is tenuous in comparison to the lateral triceps flap, which is much more robust.
The medial collateral ligament (anterior bundle) and lateral collateral ligament complex are tagged and released from their humeral attachment (TECH FIG 2B).
The shoulder is externally rotated and the elbow is flexed, allowing the ulna to separate from the humerus (TECH FIG 2C).
TECH FIG 2 • A. Triceps-splitting approach carried from the subcutaneous border of the ulna proximally into the triceps tendon. The medial and lateral triceps are subperiosteally elevated from the olecranon. B. The medial and lateral collateral ligaments are released from their humeral attachment and tagged for later repair. C. The elbow is dislocated with flexion of the joint, allowing the ulna to separate from the humerus. This separation provides exposure for component insertion. (Courtesy of Tornier, Inc., Edina, MN.)
IMPLANTATION
Humeral Preparation
Sizing of the implant to the patient’s native anatomy is critical. Trial spools should be compared to the distal humerus and the proximal radioulnar joint for appropriate sizing (TECH FIG 3A,B). If the native joint size is between spool sizes, the smaller spool is selected.
The medial and lateral points of the axis of rotation through the distal humerus are determined and an axis pin is placed through these two points, thereby replicating the axis. A drill guide aids in reproducing these points (TECH FIG 3C).
The central portion of the distal humerus articulation is removed, the intramedullary canal is opened, and a rod is placed in the intramedullary canal. The axis pin is replaced to determine the offset of the intramedullary canal relative to the flexion–extension axis (TECH FIG 3D,E).
A distal humeral cutting block is used to precisely prepare the distal humerus relative to the intramedullary canal and the flexion–extension axis (TECH FIG 3F,G).
The humeral canal is sequentially broached to the size selected for the articular spool.
Ulnar Preparation
Preparation of the ulna is based on the flexion–extension axis of the proximal radius and ulna. The selected size spool is attached to the cutting guide, and the guide is tightened with set screws (TECH FIG 4A). Care must be taken to maintain the relationship of the trochlea and capitellar portions of the spool with the native greater sigmoid notch and radial head.
A bell saw is used to resect a small portion of the articular surface and subchondral bone of the ulna (TECH FIG 4B).
If the radial head is going to be replaced, a sagittal saw is used to resect the radial head through the cutting guide. The canal is broached and a trial radial head component is inserted.
The ulnar canal is opened and sequentially broached to the same size as the selected humeral component.
Component Placement
If the replacement is going to be unlinked, a short ulnar component can be used. If the implant is going to be linked, a standard (longer) stem is selected. If a standard ulnar component is going to be used, flexible reamers may be required to prepare the ulna.
Trial reduction is performed to assess the alignment, stability, and tracking of the components.
If the components are going to be inserted unlinked, the collateral ligaments are reattached to the anatomic origin through the humeral implant. An accessory box stitch could be placed through the ulna and humeral component to support the collateral ligament repair.
The canals are lavaged and cement restrictors are placed in the humerus and ulna.
Antibiotic-impregnated cement is injected into the canals. Methylene blue is added to the cement to facilitate cement removal if required in the future.
TECH FIG 3 • The anatomic spool is sized against the native distal humerus (A) and the proximal radioulnar articulation (B). C. The native flexion–extension axis is determined. A drill guide assists in accurately establishing the flexion–extension axis. Next, the offset of the distal humeral articulation with respect to the intramedullary canal is determined. D. The relationship between the axis of flexion–extension and the intramedullary canal is determined. E. Measurement guides are used to determine whether the offset is anterior, posterior, or neutral. F. A cutting block is placed relative to the flexion–extension axis. G. The cutting block is fixed to the humerus with pins and the guide is removed. Once all of the holes are drilled, the cutting block is removed and the holes are connected with an oscillating saw. (Courtesy of Tornier, Inc., Edina, MN.)
TECH FIG 4 • A. The selected anatomic spool is attached to the ulnar cutting jig. The set screws are tightened, taking care to ensure the anatomic spool stays firmly opposed to the native radius and ulna. B.With the ulnar cutting guide properly aligned, a bell saw is used to prepare the proximal ulna. The radial head can also be removed using the same cutting jig. (Courtesy of Tornier, Inc., Edina, MN.)
LIGAMENT REPAIR
A locking stitch is used to repair the collateral ligaments through the cannulated humeral bolt (TECH FIG 5A).
Further support is achieved using a cerclage stitch passed through the humeral bolt and a transverse drill hole in the ulna (TECH FIG 5B).
TECH FIG 5 • A. The medial and lateral collateral ligaments are reattached to the epicondyles using a locking stitch that is passed through the cannulated humeral screw. B. The collateral ligament repair is reinforced with a box stitch passed through the cannulated humeral screw and a transverse hole placed through the proximal ulna. (Courtesy of Tornier, Inc., Edina, MN.
TRICEPS REPAIR
Triceps repair is crucial for the stability of unlinked devices.
The triceps is reattached through two crossing drill holes and one transverse drill hole in the olecranon.
A grasping suture (Krackow stitch) is used and passed through the crossing drill holes.
A cerclage stitch is passed through the transverse drill hole around the triceps attachment (TECH FIG 6).
TECH FIG 6 • The triceps is repaired to the ulna through drill holes. The split in the triceps and between the anconeus and flexor carpi ulnaris is closed side to side with interrupted or running suture. (Courtesy of Tornier, Inc., Edina, MN.)
WOUND CLOSURE
The ulnar nerve is transposed into an anterior subcutaneous pouch.
The wound is closed over a drain placed in the subcutaneous position.
POSTOPERATIVE CARE
The arm is placed in a well-padded postoperative dressing and the arm is immobilized in about 90 degrees of flexion for the first several days.
A resting elbow splint at 90 degrees with the wrist included is fabricated before discharge to protect the soft tissue repair while it heals.
OUTCOMES
Most studies in the literature reporting on TEA involve large numbers of patients, mostly with rheumatoid arthritis or other inflammatory pathologies but very few patients with primary osteoarthritis.
This makes it difficult to make accurate conclusions on the value of this treatment option for this population of patients.5,14,20,27
There are few studies in the English literature reporting specifically on the outcome and complications of TEA as a treatment option for patients with primary osteoarthritis of the elbow.4,13
Kozak13 reported on the Mayo clinic experience.
Over a 13-year period, only 5 of 493 patients (<1%) who underwent TEA had the procedure performed for primary osteoarthritis of the elbow.
A linked Coonrad-Morrey implant (Zimmer, Warsaw, IN) was used in three patients and an unlinked Pritchard elbow resurfacing system (ERS) (DePuy, Warsaw, IN) was used in the other two patients.
The average age of the patients was 67 and follow-up ranged from 37 to 121 months.
Two minor and four major complications were reported in four elbows, two of which required revision.
This rate of complications, according to the authors, is much higher than the rate of complications reported in TEA performed for other reasons in the same institution during the same period of time, including revision TEA, posttraumatic arthritis, nonunion of distal humerus, and rheumatoid arthritis.12,18,19
Espag et al4 reported on 11 Souter-Strathclyde cemented unlinked primary TEAs in 10 patients with osteoarthritis of the elbow.
The diagnosis was primary osteoarthritis of the elbow in nine patients and posttraumatic osteoarthritis in two patients.
The average age of the patients was 66 years; mean follow-up was 68 months.
Only one patient required revision after 97 months for ulnar component loosening.
All patients reported good symptomatic relief of pain and a significant increase in range of motion, and all patients considered the procedure to be successful.
The authors compared these results with the result of Souter-Strathclyde TEA used in patients with rheumatoid arthritis.27,31
The revision rate in their series (9%) performed for ulnar component loosening compares favorably with the revision rate with the rheumatoid patients (5% to 21%), in which the main indications for revision included dislocation, and perioperative fracture.
The authors attributed the decrease in the incidence of periand postoperative fracture to the good amount of bone stock in patients with primary osteoarthritis of the elbow, which makes the risk of fracture very minimal.
As evident from this review, the outcome studies of TEA in patients with primary osteoarthritis of the elbow are very limited. The above-mentioned studies included a small number of patients, and no final recommendation could be drawn at this time.
It is hoped that a greater understanding of elbow anatomy and kinematics will lead to advances in prosthetic design and surgical technique.
The newer anatomic unlinked implants may improve the outcome of elbow replacement in younger patients.7
More outcome studies are needed on these implants or any other modern implants before openly recommending elbow replacement in younger active patients with primary osteoarthritis of the elbow.
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