Introduction

Open debridement of the elbow remains the mainstay of treatment for moderate to severe arthritis. However this statement fails to recognize the difficulties the surgeon faces when formulating a treatment plan for patients with ‘arthritis’ of the elbow. There are many causes, many operations with many failures in patients who have many expectations.

Background/aetiology

Historically the treatment for painful elbow ankylosis was a resection arthroplasty; resection of the painful joint was achieved by excising the entire olecranon, radial head and distal humerus above the condyles (Fig. 40.1A). Whilst in most cases this gave good pain relief, instability was common as there were no soft tissue or bony stabilizers remaining after surgery. Stability relied purely on the fibrous scar tissue between the cut bone surfaces. Despite this, good results were reported in posttraumatic, tuberculosis and rheumatoid arthrirtis.^2–4 Defontaine introduced the interposition as a refinement to the resection arthroplasty in 1887.⁵ By removing less bone and leaving a fulcrum between the olecranon and the distal humerus, he addressed the difficulty of instability experienced in resection arthroplasty (Fig. 40.1B). Tissue was positioned in the joint to act as a spacer, keeping the collateral ligaments functional and providing a pain-free articulation. The material used was varied and included muscle transposition, skin, fat or even pig’s bladder. Despite the use of an interposition graft, however, because less bone was excised, stiffness and even reankylosis could still be a problem. Hass cut the distal humerus into a wedge with the idea of reducing bone contact while still providing a fulcrum, however, pain, stiffness and wear of the articulation remained a persistent problem.⁶ Schüller first published the use of interposition in rheumatoid elbows in 1893. Hurri et al reported on 76 rheumatoid elbows and found that interposition arthroplasty provided better stability compared with the group of patients who had had a resection arthroplasty alone.³ However, their results also showed that only 40% were pain-free compared with 64% in the resection group. These were also the findings of Buzby, who concluded that patients were happier with a pain-free, flail elbow than they were with the more stable but painful interposition arthroplasty, the surgery often providing only a few degrees of extra motion.² Even in these early reports it became clear that movement was always achieved at the expense of stability, while movement with stability resulted in less predictable pain relief (Fig. 40.2).⁴

Figure 40.1 Resection arthroplasty of the elbow. (A) Extraperiosteal resection arthroplasty had high rates of instability. (B) The extent of the resection arthroplasty with the facial interposition. The ‘V’ cut maintains a fulcrum and is resurfaced with facia.

Figure 40.2 Relationship of range of motion, pain and instability during surgical release and debridement. As the range of motion is increased the elbow is subject to increasing instability (A). Gaining movement while maintaining stability can result in continuing pain (B).

In 1971, Peterson and Janes published the experience from the Mayo clinic, which identified a spectrum of pathology in the rheumatoid elbow; those with deranged mechanics and those patients whose primary complaint was pain.¹ In patients whose primary complaint was pain, a limited open debridement, synovectomy with radial head excision produced better results than interposition. The use of interposition arthroplasty has declined with the increasing success of total elbow arthroplasty, which gives better pain-free range of motion and stability in the low-demand patient.

It was not until the 1970s that Minami⁷ and Kashiwagi⁸ published the first papers giving a detailed description and recommended treatment option for less severe elbow osteoarthritis. A procedure first described by Outerbridge and then published by Kashiwagi became known as the Outerbridge–Kashiwagi procedure. In 1992 this was modified by Morrey, who used a trephine to remove osteophytes encroaching on the olecranon and coronoid fossae, with elevation rather than splitting of the triceps, the so-called ulnohumeral arthroplasty.⁹ The column procedure approached the elbow via a lateral incision, debriding osteophytes and releasing the capsule through both anterior and posterior intervals. A more extensive debridement arthroplasty was described by Tsuge and Mizusek, which involved a formal disarticulation of the joint, with or without release of the collateral ligaments, excision of the capsule and reshaping of the radial head.¹⁰

As each refinement in surgical technique has evolved, so has our understanding of their limitations and the patients they will benefit. Each development has removed patients from the list that previously would have received a fusion or resection arthroplasty, leaving only a few for whom there is no alternative. Less invasive techniques with more predictable results now benefit patients who traditionally would not have been offered surgery at all. This chapter looks at open debridement and interposition arthroplasty and identifies those patients who will benefit from them. The preferred technique, with tips and tricks, is illustrated and the published results are reviewed.

Presentation, investigation and treatment options

The decision to operate and which procedure to perform is reached following a careful history, examination and investigations. Some specific questions should be answered to help in the decision-making process.

History

The patient’s age and occupation is important. Find out why the patient has consented to treatment. While most patients will complain of both pain and loss of movement, one is often more of a problem than the other. Is the loss to range of movement functionally significant? Does it stop them doing their job? If so, document whether it is flexion or extension which is the main limiting factor. This will guide you into which soft tissues or bone needs to be debrided to give the elbow a functional range of movement (Fig. 40.3). Can the patient reduce the demands on the elbow or even change jobs?

Figure 40.3 The anatomy which blocks flexion/extension. (A) Bone and soft tissue which block flexion. (B) Bone and soft tissue which block extension. (C) Lateral margins of osteophytes.

Are there symptoms of locking, clicking or instability? Locking and clicking suggest loose bodies which can be easily removed without the need to proceed to a more extensive debridement. Has the patient got any distal neurological symptoms, such as sensory disturbance or muscle weakness? In this case the ulnar nerve will need to be addressed. Even in the presence of marked radiographic degenerative changes, when neurological symptoms are the main complaint, ulnar nerve release alone can adequately relieve symptoms.

If trauma is involved, the exact mechanism, the fracture pattern, and orientation and management is useful information. If it is an inflammatory arthropathy, other joints which are affected must be noted, as they can have an impact on the function of the elbow, along with the medications and current status of the disease process. Aetiology of the arthritis will give important information as to the condition of the bone and soft tissues prior to surgery. I specifically enquire about any history of previous infection.

It is also important to ascertain patient expectations. They must be realistic as the elbow is not going to be returned to normal. The literature suggests an increase in the arc of motion of between 22° and 35° can be expected and is dependent on patient compliance with postoperative physiotherapy. They must be made aware that pain relief after open debridement can be modest and the range of motion will deteriorate with time. If there is any doubt as to their commitment to the process then surgery should not be offered.

Summary Box 40.2

• Discuss ways in which the patient might manage at home or work without having an operation.

• Really get to the bottom of what is causing the main problem. Even in the presence of gross radiological degenerative changes, can you get away with reducing the level of pain with less radical surgery? That is, management of loose bodies, ulnar nerve or radial head alone.

• Realistic patient expectations and commitment to the rehabilitation are vital.

Clinical examination

There are several specific points that must be looked at in the examination prior to surgery. On inspection look for previous surgical incisions and the quality of the skin, consider whether your surgery can be approached through the old scar.

Is pain limited to the endpoint of movement, suggesting impingement due to osteophytes which can be removed? Or, is it throughout the arc of movement, suggesting intra-articular wear, which is less likely to benefit from joint preserving open debridement (Fig. 40.4). Does the endpoint have a solid, bony block to it, or is it soft and springy, which would suggest a soft tissue contracture.

Figure 40.4 (A,B) Radiographic appearances of intrinsic wear.

Management of the ulnar nerve

If the patient has had previous surgery, the ulnar nerve may have been transposed and palpation may help with its location. I believe that you should always assume it has not been previously transposed, and a full exploration should take place before approaching the medial side of the elbow. Even in documented cases of previous transposition the nerve might have slipped back into its groove. Measurement of flexion and extension is important in the management of the ulnar nerve. When there has been longstanding loss of elbow flexion, the nerve can become contracted as it passes behind the medial epicondyle. With the sudden increased in flexion achieved after surgery the nerve does not have time to adjust and stretch out to length; this traction can cause postoperative ulnar nerve symptoms. Therefore after decompression of the ulnar nerve, it should be assessed for tension or subluxation and transposed if required. Examination should include an assessment of the cervical spine, as radicular symptoms round the elbow can be misleading.

Palpation of the radiocapitellar joint

A worn radiocapitellar joint can be pain-free at examination, suggesting it is not involved in the pathological process and can therefore be left alone. A radiocapitellar joint that appears worn on visual inspection during surgery is not always a cause of pain, and unnecessarily removing it can cause problems. On the other hand the clinical finding of a painful radiocapitellar joint requires direct inspection at surgery and if this confirms disease, the head should be excised.

Trauma and instability

Accurate examination of the lateral and medial collateral ligaments is difficult; however, any gross instability should be assessed. In cases of trauma, non-union and malunion should be identified, as these may require fixation and bone grafting at surgery. In posttraumatic cases where the anatomy may have been altered, arthroscopic debridement carries a high risk of an iatrogenic injury to neurovascular structures.¹⁷