Elbow Arthritis

Author: David Abbasi

Topic updated on 04/24/13 8:17pm

Introduction

Can be seen in
- association with dominant hand
- men to women 4:1
- middle aged laborers
- MUCL or ligamentous insufficiency
Etiologies
- rheumatoid arthritis
  - most prevalent form with 50% of patients affected
  - causes progressive bone resorption and osteopenia
- post-traumatic arthritis
  - second most common form
- primary arthritis
  - rare
  - common in middle-aged male laborers
- history of osteochondritis dissecans

Anatomy

Elbow anatomy and biomechanics

Presentation

History
- progressive pain
- loss of terminal extension
- painful locking of elbow
Physical exam
- loss of elbow range of motion
- ligamentous incompetence can be seen
  - especially in rheumatoid arthritis
- ulnar neuropathy present in up to 50% of patients

Imaging

Radiographs
- elbow joint space narrowing
- osteophytes
  - coronoid process and fossa
  - especially in olecranon tip and posteromedial olecranon fossa
- loose bodies
CT scan
- 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
  - technique
    - removal of osteophytes and loose bodies
    - often combined with soft tissue release
- ulnohumeral distraction interposition arthroplasty
  - indications
    - young high demand patients
  - technique
    - can use
      - autogenous tensor fascia lata
      - achilles tendon allograft
    - 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
    - complex distal humerus fracture in elderly with poor bone stock
  - technique
    - 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

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Qbank (1 Questions)

TAG

(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

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

PREFERRED RESPONSE ▶

DISCUSSION: Total elbow arthroplasty is the most established definitive surgical treatment for severe rheumatoid arthritis. This patient has pain and loss of function with radiographs that show degenerative changes consistent with rheumatoid arthritis. This would be classified as a Larson grade C with bony architectural changes on its way to joint destruction (Grade D). This is the original indication for total elbow arthroplasty.

The Kokkalis article is a current concepts review which covers other indications and results.

The Skytta paper is from the Finnish joint registry and looks at the survival rates of different total elbow implant designs. Linked implants have shown improved survival.

REFERENCES:

1. Skytta ET, Eskelinen A, Paavolainen P, Ikavalko M, Remes V. Total elbow arthroplasty in rheumatoid arthritis. Acta Orthop. 2009 Jan 1:1-6. PMID:19562563 (Link to Abstract)

2. Kokkalis ZT, Schmidt CC, Sotereanos DG. Elbow arthritis: current concepts. J Hand Surg Am. 2009 Apr;34(4):761-8. Review PMID:19345885 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, John Badylak MD, Jan Szatkowski MD,

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Videos

Elbow arthroscopy for elbow arthritis

Sports - Surgical Techniques - Elbow Arthritis

Video contains short lecture followed by arthroscopic video for elbow arthritis....

6/4/2012

174 views

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Groups

ABOS II: Elbow Arthritis

General - Oral Boards Review

7/29/2011

0 responses

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Evidence & References Show References

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Kokkalis ZT, Schmidt CC, Sotereanos DG. Elbow arthritis: current concepts. J Hand Surg Am. 2009 Apr;34(4):761-8. Review PMID:19345885 (Link to Abstract)
Skytta ET, Eskelinen A, Paavolainen P, Ikavalko M, Remes V. Total elbow arthroplasty in rheumatoid arthritis. Acta Orthop. 2009 Jan 1:1-6. PMID:19562563 (Link to Abstract)

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