Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Images
https://upload.orthobullets.com/topic/3084/images/SA05-UE17---fig-8_moved.jpg
https://upload.orthobullets.com/topic/3084/images/elbowct.jpg
https://upload.orthobullets.com/topic/3084/images/unconstrained2..jpg
    • 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
    • Ulnar nerve neuritis/injury
      • Can be iatrogenic injury or after restoration of elbow motion without nerve decompression  
    • Triceps avulsion
    • Fracture
    • Aseptic loosening
      • Risk factors
        • linked implants
        • post-traumatic osteoarthritis
    • Implant failure (mechanical)
    • Instability
      • Risk factors
        • unlinked implants
Card
1 of 1
Question
1 of 15
Private Note