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
Technique Guide CPT Codes: 24363 Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow) Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Total Elbow Arthroplasty with Triceps-Reflecting Approach, Supine Team Orthobullets (D) Shoulder & Elbow - Elbow Arthritis Technique Guide CPT Codes: 24363 Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow) Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. TEA Diamond Popup Technique Team Orthobullets (D) Shoulder & Elbow - Elbow Arthritis
QUESTIONS 1 of 12 1 2 3 4 5 6 7 8 9 10 11 12 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ19SE.40) A 75-year-old female with rheumatoid arthritis presents to your clinic with complaints of long standing elbow pain. She has a 20º flexion contracture on examination and pain diffusely about the elbow. There is a soft tissue nodule noted to be overlying the elbow. Her radiograph is seen in Figure A. Which of the following is true regarding the development and management of the most likely pathologic process? QID: 216861 FIGURES: A Type & Select Correct Answer 1 Disease process causes proteoglycan and collagen destruction 42% (499/1202) 2 Osteophytes are most characteristic radiographic changes seen 3% (38/1202) 3 Has poorer results when treated with total elbow arthroplasty compared with primary osteoarthritis 21% (251/1202) 4 Should be managed with unconstrained total elbow arthroplasty 9% (107/1202) 5 Rheumatoid factor mutation is responsible for abnormal elbow synovial proliferation 25% (296/1202) L 5 Question Complexity Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ08UE.45.1) Figure A is the radiograph of a 68-year-old man presents to your office with complaints of elbow pain. He reports that 9 years prior he underwent an interposition arthroplasty for end stage osteoarthritis of the ulnohumeral joint. He now reports that for the two past years he has had increasing pain and elbow instability. There is no clinical evidence of infection, and radiographs show no new bony process. What is the best definitive treatment for this patient? QID: 216478 FIGURES: A Type & Select Correct Answer 1 Conservative care to include physiotherapy 5% (43/946) 2 Arthrodesis 5% (43/946) 3 Revision interposition arthroplasty 2% (23/946) 4 Conversion to distal humerus hemiarthroplasty 3% (26/946) 5 Conversion to total elbow arthroplasty 85% (800/946) L 4 Question Complexity Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
All Videos (6) Podcasts (2) Orthopaedic Summit Evolving Techniques 2020 Evolving Technique: Post-Traumatic Radiocapitellar Arthritis: My Approach To This Challenging Problem - Graham King, MD Graham King Shoulder & Elbow - Elbow Arthritis 9/15/2022 275 views 0.0 (0) Login to View Community Videos Login to View Community Videos Cleveland Combined Hand Fellowship Lecture Series 2020-2021 Elbow Arthritis: Case of the Week - Shaan Patel, MD Shaan S. Patel Shoulder & Elbow - Elbow Arthritis B 8/5/2021 34 views 0.0 (0) Login to View Community Videos Login to View Community Videos Cleveland Combined Hand Fellowship Lecture Series 2020-2021 Elbow Stiffness - Bill Zuke, MD Shoulder & Elbow - Elbow Arthritis B 5/7/2021 32 views 0.0 (0) Shoulder & Elbow⎜ Elbow Arthritis (ft. Dr. Matthew L. Ramsey) Team Orthobullets (J) Shoulder & Elbow - Elbow Arthritis Listen Now 12:51 min 10/18/2019 63 plays 0.0 (0) Shoulder & Elbow⎪Elbow Arthritis Shoulder & Elbow - Elbow Arthritis Listen Now 18:58 min 2/11/2020 176 plays 5.0 (1) See More See Less
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