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