Primary Osteoarthritis of the Elbow

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Chapter 38 Primary Osteoarthritis of the Elbow

David Stanley

Introduction

Primary osteoarthritis of the elbow is a relatively uncommon condition mainly affecting middle-aged men. It is characterized by wear of the articular cartilage together with new bone formation at the joint surfaces.¹ The condition is normally progressive, although the speed of progression is variable. In the general population it has a prevalence of between 1.3 and 2.0%,^2,³ although Doherty and Preston working in a rheumatological clinic noted a prevalence of 7%.⁴

Background/aetiology

The natural history of articular cartilage changes within the elbow has been investigated by Goodfellow and Bullough.⁵ They examined 28 elbow joints retrieved at autopsy in subjects aged 18–88 years. They noted that with increasing age the radiocapitellar joint almost invariably showed degenerative change with a posteromedial radial head ulcer (Fig. 38.1A,B). Associated with this was an area of linear ulceration of the humeral crest between the trochlea and the capitellum. By contrast the cartilage of the ulnar-trochlear joint rarely showed evidence of degeneration. In older subjects grooves in the articular cartilage of this articulation were seen, although these did not expose the underlying bone. It was suggested that the differences in the pattern of wear between the radiocapitellar and ulnar-trochlear joints were related to the fact that the radiocapitellar joint has a combination of flexion, extension and rotational movements, whereas the ulnar-trochlear joint has only flexion and extension.

Figure 38.1 (A) Posteromedial radial head ulceration. (B) Marked degeneration affecting the capitellum with preservation of the trochlear cartilage.

Murato et al ⁶ noted similar changes in the elbow with ageing and concluded that there was a progression of change from normal ageing to the development of elbow osteoarthritis. They found that the degenerative change in the radiocapitellar joint was always more advanced than in the ulnar-trochlear joint.

Osteoarthritis of the elbow is characterized by joint space narrowing, osteophyte formation, sclerosis and loose body formation. In addition, the olecranon fossa membrane, which is normally a thin sheet of bone, is invariably thickened.

Kashiwagi ⁷ and Tsuge and Mizuseki⁸ noted erosion of the radial head with reciprocal loss of cartilage over the capitellum. Osteophytes occur around the radial head, but are predominantly seen at the tip of the olecranon and coronoid process. They may also be present around the olecranon and coronoid fossae.⁹ Osteophytes involving the medial aspect of the joint may also compress the ulnar nerve resulting in symptoms of ulnar neuritis. Bell¹⁰ first reported the presence of loose bodies within the elbow and Morrey¹¹ has suggested that these occur in up to 50% of patients with elbow osteoarthritis. These loose bodies may be single or multiple and can be found in any compartment of the joint.

Thickening of the olecranon fossa membrane was originally noted by Kashiwagi ⁷ when he performed the Outerbridge–Kashiwagi procedure. More recently a histological study has shown that the anterior and posterior cortices, together with the intramedullary bone of the olecranon fossa membrane, are all thickened in this condition.¹²

The aetiology of elbow osteoarthritis is not fully understood. Repetitive trauma is undoubtedly an important factor, but it is probable that other influences particularly genetic factors are also relevant in the development of this condition (Fig. 38.2).

Figure 38.2 Proposed interaction of genetic and environmental factors in the development of osteoarthritis of the elbow.

Holtzmann ¹³ in a study of heavy manual workers suggested that the use of pneumatic tools might be an important predisposing influence. This view was supported by Rostock,¹⁴ who found that miners using pneumatic boring equipment experienced osteoarthritis of the elbow more commonly than shoulder or wrist osteoarthritis. Lawrence¹⁵ noted that 31% of miners using pneumatic drills for more than1 year developed elbow osteoarthritis compared with only 16% who had not drilled. Other authors, however, have failed to show an association with this type of work.^16,¹⁷

Of greater significance was the finding from Lawrence’s study ¹⁵ that in miners the elbow was the third most frequently affected joint with osteoarthritis after the spine and knee. Lawrence concluded that elbow osteoarthritis was a feature of all types of heavy manual work. More recently Stanley³ has shown a statistically significant difference in the prevalence of elbow osteoarthritis in men undertaking heavy manual work compared with those doing non-manual tasks (p = 0.016).

Summary Box 38.1 Histological changes in elbow osteoarthritis

• Early radiocapitellar degeneration with lateral compartment joint space narrowing

• Preservation of the ulnar-trochlear joint until advanced disease

• Coronoid, olecranon and radial head osteophytes

• Thickening of the olecranon fossa membrane

• Loose bodies

Presentation, investigations and treatment options

Clinical presentation

Osteoarthritis of the elbow occurs predominantly in men after the fourth decade of life. The dominant extremity is usually involved, although either or both elbows may be affected. At times the condition is diagnosed when the upper limb is being assessed for an unrelated problem, although more frequently one of three main types of presentation will be observed.

• Aching discomfort and reduced elbow movement – This is probably the most frequent presentation. The patient usually complains of aching discomfort in the elbow with an inability to fully extend the joint. Occasionally, there may also be slight loss of flexion. Gripping and forearm rotation movements often exacerbate symptoms due to degenerative change at the radiocapitellar joint.

• Acute pain and locking – Acute pain may be secondary either to posterior or anterior elbow impingement, or may result from the presence of loose bodies. Posterior impingement pain occurs when the tip of the olecranon impacts in the olecranon fossa during maximal extension with anterior impingement pain occurring when the tip of the coronoid process impacts in the coronoid fossa on full flexion. Single or multiple loose bodies may be present in either the anterior or posterior compartments of the elbow and can also occur in the medial or lateral elbow gutters. They cause acute pain together with reduced elbow movement if they ‘lock’ within the joint.

• Ulnar nerve irritation – This may occasionally be the sole reason for orthopaedic referral but more commonly occurs in combination with the presentations mentioned above. Careful clinical examination will reveal some evidence of an ulnar nerve abnormality in up to 50% of patients.⁷

Clinical Pearl 38.1

Always remember to carefully assess the ulnar nerve when examining a patient with suspected osteoarthritis of the elbow.

Investigations

Anteroposterior and lateral radiographs are usually the only investigations required to make the diagnosis (Fig. 38.3). These usually show the characteristic features of the condition with osteophytes at the tip of the olecranon and coronoid process, narrowing of the radiocapitellar joint space, radial head osteophytes, loss of definition of the outline of the olecranon fossa due to thickening of the interfossa membrane and loose body formation.⁹ When multiple loose bodies are present, computed tomography allows confirmation of the number of loose bodies within the joint, together with the location and identifies the extent of osteophyte formation (Fig. 38.4).

Figure 38.3 (Ai,ii) Anteroposterior and lateral radiographs showing the characteristic features of osteoarthritis of the elbow with loss of the radiocapitellar joint space, loss of the olecranon fossa outline due to thickening of the olecranon fossa membrane and osteophyte formation. (B) Loose bodies are seen in the olecranon fossa.

Figure 38.4 (A) CT scan of (3B) showing loose bodies in the olecranon fossa. (B) CT scan showing narrowing of the radiocapitellar joint space with preservation of the ulnar trochlear joint space.

Patients presenting with ulnar nerve symptoms should undergo electromyographic assessment in order to both confirm the diagnosis and identify the site of ulnar nerve compression.

Clinical Pearl 38.2

Anteroposterior and lateral radiographs are usually sufficient to confirm a diagnosis of osteoarthritis of the elbow.

Treatment options

It is obviously important that all patients are made aware of their diagnosis and that this is the cause of their symptoms. Those with minor complaints may find conservative management beneficial. The use of simple analgesics or non-steroidal antiinflammatory drugs may relieve symptoms, and on occasion an intra-articular steroid injection can also be of benefit.⁴

When conservative treatment fails a number of surgical options are available. These depend on the severity of the disease and the surgical experience of the surgeon. Techniques that have been reported to alleviate symptoms are both arthroscopic or open debridement procedures, ulnar nerve surgery and total elbow arthroplasty.

Surgical techniques and rehabilitation

Arthroscopic debridement

The arthroscopic treatment of osteoarthritis of the elbow is becoming increasingly popular. It is, however, dependent on the surgeon having a detailed anatomical knowledge of the elbow and appropriate arthroscopic expertise. These techniques have been used for the removal of loose bodies,¹⁸ debridement of osteophytes¹⁹ and for performing the ulnohumeral arthroplasty arthroscopically.^20,²¹ The surgical set up and techniques available are beyond the remit of this chapter. For a more detailed description and discussion the reader is referred to Chapter 39.

Open debridement procedures

Outerbridge–Kashiwagi procedure/ulnohumeral arthroplasty

Kashiwagi ²² reported an open debridement procedure for osteoarthritis of the elbow that he attributed to Outerbridge and described as the Outerbridge–Kashiwagi or OK method. The operation allowed the removal of loose bodies and the excision of osteophytes and was stated to relieve pain and improve flexion. Using this technique good results were obtained by both Minami and Ishii²³ and Stanley and Winson.²⁴ The procedure was later modified by Morrey,²⁵ who recommended the use of a bone trephine for fenestration of the olecranon fossa membrane in order to reduce bone debris. He named the operation ulnohumeral arthroplasty.

The operation is performed under tourniquet control with the patient supine on the operating table and with a sandbag under the ipsilateral shoulder. With the arm across the chest an 8 cm midline incision is made extending proximally from the tip of the olecranon (Fig. 38.5). The incision is deepened and the triceps is split in the line of its fibres. The posterior capsule is then opened and any loose bodies in this compartment are removed (Fig. 38.6). Osteophytes at the tip of the olecranon and around the olecranon fossa are excised. A bone trephine of approximately the same size as the olecranon fossa is then used to fenestrate the thickened olecranon fossa membrane allowing access to the anterior compartment of the elbow (Fig. 38.7). By flexion and extension of the elbow anterior loose bodies will present themselves at the fenestrated fossa and can be easily removed. In addition by maximal flexion of the elbow osteophytes at the tip of the coronoid process can be excised through the fenestration using a fine osteotome. The elbow is then thoroughly washed out and the wound closed over a suction drain. A dressing of orthopaedic gauze, wool and crepe is applied and the arm is supported in a broad arm sling. The drain is removed within 24 hours and the dressing reduced. The patient is then encouraged to undertake progressive range of movement and strengthening exercises.

Figure 38.5 The skin incision for the Outerbridge–Kashiwagi procedure/ulnohumeral arthroplasty.

Figure 38.6 The triceps has been split and the posterior compartment of the elbow entered. Loose bodies in this compartment can be removed and osteophytes excised.

Figure 38.7 The olecranon fossa membrane has been fenestrated allowing access to the anterior compartment of the elbow.

Morrey ²⁵ uses a more aggressive postoperative rehabilitation regimen with a continuous brachial plexus block for 1–3 days together with the use of continuous passive motion. In addition, active movement is encouraged and the patient is provided with a hinged splint to maintain both flexion and extension.²⁶ Postoperative anteroposterior and lateral radiographs will confirm that appropriate debridement has been achieved (Fig. 38.8).

Figure 38.8 (A,B) Pre- and postoperative radiological appearances following an ulnohumeral arthroplasty.

Tsuge debridement procedure

Tsuge and Mizuseki ²⁷ described a more extensive debridement procedure for advanced primary osteoarthritis of the elbow. Via a posterior incision the ulnar nerve is identified and protected and the extensor mechanism reflected medially. The radial collateral ligament and the posterior part of the ulnar collateral ligament are divided and the joint dislocated (Fig. 38.9). Loose bodies are removed and osteophytes excised. The shallow olecranon, coronoid and radial fossae are deepened with a burr and the anterior capsule released to improve extension. If there is restricted rotation the radial head can be trimmed and reshaped to improve pronation and supination. Postoperatively, continuous passive motion is used for 7 days.

Figure 38.9 Tsuge debridement arthroplasty for advanced primary osteoarthritis of the elbow.

Ulnar nerve surgery

Compression of the ulnar nerve is not uncommon with osteoarthritis of the elbow and may result from medial joint osteophytes or thickening of the fascia overlying the cubital tunnel. The clinical diagnosis and site of compression should be confirmed electromyographically after which decompression of the nerve should be undertaken. For the techniques of ulnar nerve decompression, the reader is referred to Chapter 31.

Total elbow arthroplasty

Although total elbow arthroplasty has been shown to be an effective treatment option in rheumatoid arthritis, the indications for its use in osteoarthritis are more limited.²⁸ The procedure should not be undertaken in young adults who wish to perform manual tasks and is only suitable for those over the age of 65 who have low activity levels, pain throughout the range of movement and in whom all other treatment options have failed. In addition if a total elbow arthroplasty is contemplated the patient must accept a lifetime ban on lifting weights of more than 4.5 kg (10 lb) or repetitive lifting of more than 1 kg (2 lb).²⁹

Surgery is performed under tourniquet control. The patient is positioned either supine with a sandbag under the ipsilateral shoulder and with the arm across the chest or, as is my preference, with the patient lateral, the arm horizontal and with the forearm hanging vertically. A posterior skin incision is made centred at the tip of the olecranon and skin flaps elevated to allow identification and superficial decompression of the ulnar nerve. The nerve is then mobilized to enable the arthroplasty to be performed safely or, alternatively, formally anteriorly transposed. Several surgical approaches to the elbow joint have been reported and a number of implants utilized. Further information is given in Chapter 43. Essentially the elbow can be exposed using a triceps splitting, triceps reflecting or triceps sparing approach. The elbow is then dislocated and bone resection undertaken depending on the type of arthroplasty being inserted.

At the time of insertion of the trial prosthesis it is important to check that during flexion and extension there is no evidence of impingement or pistoning of the implant as this will result in early loosening. After the definitive prosthesis has been inserted the triceps mechanism must be securely repaired in order for the patient to regain active elbow extension.

Postoperatively the arm is elevated in a well-padded backslab with the elbow in extension. The back slab is removed after 48 hours and the wound inspected. Provided the wound is satisfactory the patient is allowed to undertake progressive gentle elbow flexion and extension exercises.

Outcome including literature review

Arthroscopy

The early results of arthroscopic debridement of the osteoarthritic elbow have been encouraging ^19,²⁰ and more recent studies have shown reduction in pain, together with improved range of movement and patient satisfaction.^21,³⁰ Arthroscopic ulnohumeral arthroplasty has been shown to reduce elbow pain but has not always shown an improvement in range of movement.²⁰ If, however, additional arthroscopic anterior and posterior capsular releases are performed, some improvement in range of movement can be expected.³¹

Debate exists as to whether excision of the radial head should be part of the arthroscopic procedure. Kelly et al ³⁰ advised against it whereas McLaughlin et al³² noted better outcomes when radial head excision alone was performed than when it was combined with ulnohumeral arthroplasty.

Open debridement procedures

Outerbridge–Kashiwagi procedure/ulnohumeral arthroplasty

Minami et al ³³ reported their experience of 44 osteoarthritic elbows that had been treated with Outerbridge–Kashiwagi arthroplasty and followed for 8–16 years. At a mean follow-up of 10 years 55% had no or minimal pain, 76% had improved flexion and 55% improved flexion. Phillips et al³⁴ reviewed 20 patients at an average of 75 months postoperatively and noted that although there was some evidence of progressive closure of the olecranon fossa fenestration, this did not appear to affect the clinical outcome. Antuna et al³⁵ reviewed 46 elbows at a mean follow-up of 80 months. Seventy-five per cent were considered to have had a satisfactory outcome. This study did, however, identify that patients with ulnar nerve symptoms that were not addressed at the initial debridement procedure had a less satisfactory outcome.

Cohen et al ³⁶ compared the results of arthroscopic and open debridement of the osteoarthritic elbow. At a follow-up of approximately 3 years, those patients undergoing arthroscopic surgery had superior pain relief whereas those who had open surgery had a better range of movement.

Tsuge debridement procedure

In 29 elbows, Tsuge and Mizuseki ²⁷ reported an average gain in range of movement of 34° at a mean follow-up of 64 months. Grip strength and pain relief were also improved in most patients.

Total elbow arthroplasty

Kozak et al ³⁷ reported their experience of total elbow arthroplasty in the treatment of five patients with osteoarthritis of the elbow. At an average postoperative follow-up of 5 years the mean arc of flexion and extension was 85°. One of the two patients treated with an unlinked prosthesis had an unsatisfactory outcome but those treated with a linked prosthesis were considered to be doing well. Naqui et al³⁸ reported their results with an unlinked implant with an average follow-up of almost 5 years. In this series there is a significant reduction in pain and improvement in movement and function. At follow-up no cases had been revised and there was no evidence of any significant radiolucency. Espag et al³⁹ treated 11 osteoarthritic elbows (10 patients) using the unlinked Souter–Strathclyde prosthesis. At a mean follow-up of 68 months, seven patients were pain-free and three had persistent occasional pain especially on repetitive movement. The mean flexion/extension arc increased from 69° to 107°.

Complications of treatment

Complications may occur with any surgical procedure but only those specific to arthroscopic, open debridement procedures and total elbow arthroplasty in the treatment of primary osteoarthritis will be considered on in this chapter.

Arthroscopy

Arthroscopy of the elbow has a higher complication rate than any other joint arthroscopic procedure. This is related to its complex anatomy and in particular the close proximity of neurovascular structures to the arthroscopic portals. The most common complication is transient nerve palsy, which occurs in up to 14% of reported series.30–32,40–42 Less frequent complications include infection, stiffness and myositis ossificans.

Open debridement procedures

Complications of open debridement procedures again include ulnar nerve entrapment and neuropraxia,^35,⁴³ triceps rupture⁴⁴ with a reoperation rate of 8%.⁴³ Wada et al⁴⁵ noted a recurrence of olecranon and coronoid fossae osteophytes in all patients followed for 10 years or more after ulnohumeral arthroplasty. However, a correlation between radiographic signs of recurrence and functional outcome has not been firmly established. Finally Hearnden et al⁴⁴ while confirming the improvement in pain relief and range of motion, noted that both diminished with time.

Total elbow arthroplasty

Kosak et al ³⁷ in their five osteoarthritic patients treated by total elbow arthroplasty noted complications that included implant wear and a fracture of one of the prostheses.

Espag et al ³⁹ also noted complications using the unlinked Souter–Strathclyde prosthesis. At a mean follow-up of 68 months, radiological evidence of loosening was seen around three humeral and two ulnar components, one of which required revision at 97 months.