Elbow Arthritis - Shoulder & Elbow

- 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

Action	Numeric Key	Letter Key	Function Key
Show Bullets		S	Enter (frontside only)
20%	1	N
40%	2	H
60%	3	F	Enter (backside only)
80%	4	E
100%	5	M
Toss	0	T