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Elbow Arthritis

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Topic updated on 07/16/15 12:38am
Introduction
  • Degenerative joint disease of the elbow articulation. Most common causes are
    • primary osteoarthritis
    • post-traumatic arthritis
    • inflammatory arthritis (e.g., RA)
  • 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
            • second most common form of elbow arthritis (after rheumatoid)
          • especially after nonoperatively treated radial head fractures or elbow dislocations with coronoid fracture
          • history of 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
  • 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
    • coronoid
  • 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
    • aconeus, 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 presereved early
      • ulnar neuropathy present 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 plain films preop for RA patients indicated for elbow 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
        • mild disease with bone spurs
        • mechanical block to motion
        • preferred in patients with >90 degrees of motion
      • contraindications
        • prior elbow surgery, especially ulnar nerve transposition
        • severe contracture or arthrofibrosis
      • technique
        • removal of osteophytes and loose bodies
        • often combined with soft tissue release
      • complications
        • neurologic injury
        • synovial fistula
    • ulnohumeral distraction interposition arthroplasty
      • indications
        • young high demand patients
      • technique
        • can use
          • autogenous tensor fascia lata
          • achilles tendon allograft
      • complications
        • patients with severely limited preoperative motion (extension > 60 degrees and flexion of < 100 degrees are at risk for ulnar nerve dysfunction
          • postoperatively and should undergo a concomitant ulnar nerve decompression
    • 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 extension contracture preoperatively
    • 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
      • 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
    • two primary types of prostheses, both of which provide pain relief
      • unconstrained TEA  
        • used with competent elbow ligaments and adequate bone stock
      • constrained TEA  
        • used with incompetent elbow ligaments
    • approach
      • posterior to elbow with olecranon osteotomy (tip)
      • flex and dislocate elbow
    • technique
      • prepare humerus
        • resect mid-portion of trochlea
        • identify and ream humeral canal
        • insert alignment guide into canal
        • assemble humeral cutting guide onto alignment guide
        • confirm rotation
        • make humeral cuts and remove guide
        • prepare humeral canal with rasp
        • release anterior capsule and elevate brachialis
      • prepare ulna
        • identify canal and ensure enough of tip removed to access
        • prepare canal with rasp
      • perform trial reduction 
      • clean canals with pulse lavage
      • cement ulnar component
      • cement humeral component
      • articulate the humeral and ulnar components
    • postoperative care
      • early immobilization of variable duration then
      • active motion as tolerated
      • no formal PT


 

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Qbank (1 Questions)

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(OBQ07.40) A 66 year old woman has chronic elbow pain and loss of function. She has severe morning stiffness and takes several medications for this. Exam reveals a flexion arc from 35-100 degrees with markedly limited rotation. What is the most appropriate definitive treatment? Topic Review Topic
FIGURES: A   B        

1. Total elbow arthroplasty
2. Radial head replacement
3. Radial head excision
4. Corticosteroid injection
5. Elbow arthroscopic debridement and removal of loose bodies

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