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https://upload.orthobullets.com/topic/3084/images/SA05-UE17---fig-8_moved.jpg
https://upload.orthobullets.com/topic/3084/images/olecranon osteophyte.jpg
https://upload.orthobullets.com/topic/3084/images/larsen.jpg
https://upload.orthobullets.com/topic/3084/images/elbowct.jpg
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Introduction
  • Degenerative joint disease of the elbow can be broken into three main types
    • 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
          • 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
        • 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)
      • 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
    • go to Total Elbow Arthroplasty - Indications, Outcomes, and Key Technical Concepts  
    • go to 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
 

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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? Review Topic

QID: 701
FIGURES:
1

Total elbow arthroplasty

89%

(1727/1950)

2

Radial head replacement

1%

(27/1950)

3

Radial head excision

3%

(49/1950)

4

Corticosteroid injection

2%

(35/1950)

5

Elbow arthroscopic debridement and removal of loose bodies

5%

(100/1950)

L 1

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