INTRODUCTION

Primary degenerative arthritis of the elbow is now well recognized and readily treated. Even today, the studies to better understand the condition are limited. Articular cartilage changes at the distal humerus⁴⁰ and proximal radius with aging have been observed and studied.¹⁵ More recent experience with this condition has clarified to some extent the etiology and presentation, but the greatest advances are in the treatment of this disease. ^*

INCIDENCE AND ETIOLOGY

The existence of degenerative arthritis of the elbow has been recognized by orthopedic surgeons in the past, but the etiology was generally believed to be secondary to unrecognized or repetitive trauma. The radiographic characteristics have, however, been carefully delineated by Mianami et al in 1977.²⁹ Furthermore, demographic studies have shown dramatic differences in the incidence of elbow arthritis in different races, but it is unclear if this is due to a genetic or an environmental influence.⁴³ Smith⁵⁰ clearly identified a condition that he termed osteoarthritis as a sequelae to trauma such as fracture-dislocation or “hard usage.” In fact, the condition as an overuse manifestation is rather well recognized,^3,17,32 yet only brief references to the condition are noted in the standard texts.^33,50 In addition to an increased awareness, there is some evidence that the actual incidence of the disease may be increasing.⁸

When discussed, it is thought to be related to a single or repetitive traumatic event or other predisposing conditions such as osteochondritis dissecans.^21,50,57 We concur with this opinion as a cause, at least in some. Primary osteoarthritis of the elbow has been reported as accounting for 1% to 2% of patients presenting with elbow arthritis.^7,18 This is consistent with the observation that less than 5% of joint replacement is performed in patients with this diagnosis.^24,37 Doherty and Preston¹⁰ reported an incidence of about 7% from a typical rheumatologic practice and was shown to be associated with other sites of involvement, especially of the hand (Fig. 76-1). Because of these features, recognition of the entity is still sometimes overlooked or misinterpreted as a post-traumatic condition.¹¹

FIGURE 76-1 Relative incidence of primary osteoarthritis of the elbow referable to the other joints.

(Redrawn from Doherty, M.: Primary osteoarthritis of the elbow. Ann. Rheum. Dis. 48:743, 1989.)

CLINICAL PRESENTATION

Men are, by far, more commonly affected with this condition than women at a ratio of about 4 to 1.^{11,19,29,31,38} The age at initial presentation is about 50 years,¹⁰ but I and others have observed a surprising variation ranging from 20 to 65 years.^31,38 Occupations or avocations involving the repetitive use of an extremity are the most common factors, being present in about 60% of patients. We have diagnosed this problem in persons with neuropathic conditions causing impaired ambulation and requiring continued use of crutches or a wheelchair. The dominant extremity is involved in about 80% to 90% of patients, and bilateral involvement is present in 25% to 60%.^10,38 The radiohumeral joint is involved in about 85%, but it may not be symptomatic.⁸

Stiffness may be a dominant feature.¹⁰ Loss of extension is the most common problem prompting medical attention, but mild to occasional moderate pain is also commonly present. The characteristic pain is of terminal extension in almost all patients and of terminal flexion in about 50%. Less commonly, symptoms are present throughout the arc. The intensity of pain is mild to moderate, and only occasionally is the process described as severe. The radiohumeral joint may be symptomatic in flexion, extension, and rotation.

Consistent with these features, examination reveals an arc of motion that averages about 30 to 120 degrees (Fig. 76-2). Forearm rotation is not restricted or only minimally so because the radiohumeral joint is typically not severely involved. Because of excessive osteophyte formation, ulnar nerve irritation is observed in at least 10%³¹ and we suspect in a higher number if carefully examined. Ulnar nerve involvement should be specifically sought in the examination because it may influence treatment decisions and even long-term outcome.¹

FIGURE 76-2 A and B, Primary elbow arthrosis usually presents with loss of extension in men older than 40 years of age. Most often flexion and extension are in the functional range.

LABORATORY STUDIES

Because the diagnosis is not obvious owing to its relative infrequent occurrence, arthrocentesis, synovial biopsy, and arthroscopy have all been performed to diagnose this condition.^11,39 When one is familiar with the disease, it comes as no surprise that all three of these diagnostic studies offer little if any added value.^10,38 The roentgenographic study is diagnostic, and typically no other assessment is indicated or required. The sedimentation rate is normal.

RADIOGRAPHIC FEATURES

The roentgenographic features of this condition are classic and characteristic, maybe even monotonous. The characteristic of primary osteoarthritis of the elbow is “marginal osteophyte formation.” Hence, the consistent routine anteroposterior and lateral roentgenograms reveal an anterior osteophyte of the coronoid and a posterior osteophyte of the olecranon process (Fig. 76-3).²⁹ The anteroposterior view also shows a consistent finding of ossification and osteophyte formation in the olecranon or coronoid fossa (Fig. 76-4). In the later stages, no other study is required to make this diagnosis. However, tomography may show subtle osteophyte formation, the presence and location of loose bodies, and the size and extent of the osteophytes on the humerus and ulna (Fig. 76-5). Involvement of the radial head has been documented in about 85%.⁸ Bell and Minami et al^2,31 have characterized the development of loose bodies as an integral feature of primary arthritis of the elbow. Special imaging studies are not needed and are of no value to diagnose this condition. A cubital tunnel view is sometimes obtained if the ulnar nerve shows signs of ulnar neuritis. These features do reflect the clinical expression and provide a guideline to treatment.

FIGURE 76-3 Typical lateral roentgenogram of primary osteoarthritis of the elbow demonstrating the almost monotonous pattern of osteophytes of the coronoid and olecranon processes.

FIGURE 76-4 Anteroposterior roentgenogram of the elbow demonstrating ossification of the olecranon fossa.

FIGURE 76-5 Lateral tomogram showing minimal hypertrophic radiographic changes, with a loose body both anteriorly and posteriorly.

TREATMENT

* Based on experience.

ARTHROSCOPY

Arthroscopic Management

Arthroscopic débridement of the elbow is discussed in Chapters 38 to 40; however, there have been a number of reports specifically discussing arthroscopic débridement in the face of primary osteoarthritis (Fig. 76-6).^16,23,28 These studies are summarized in Table 76-2. Although the sample is relatively small (60 patients) with a mean follow-up of just more than 3 years, it is impressive that more than 90% of patients expressed satisfaction with relief of pain and the improved arc of motion in these recent studies is greater than 60 degrees. Hence, arthroscopic débridement for primary osteoarthritis is emerging as a viable treatment option. In our opinion, the key elements to consider this option are

1. Expertise with arthroscopic surgery;

2. Familiarity with elbow pathology, specifically the pathology of primary osteoarthritis;

3. The extent the disease should not be too extensive, specifically the capacity of the joint should be such that a great deal of effort should not be expended in order to enter the joint and obtain visual landmarks;

4. The ulnar nerve should be asymptomatic; if it is not, arthroscopy can still be done but the ulnar nerve should be dealt with, in our opinion, with a specific open procedure, usually simple decompression is adequate and translocation is not necessary.

5. The postoperative regimen is important in these patients, just as it is for open procedures.

6. The ever-present potential for injury.

FIGURE 76-6 Arthroscopic appearance of primary arthrosis of the radiohumeral joint.

TABLE 76-2 Scope: Summary of the Recent Literature Regarding Arthroscopic Treatment for Primary Osteoarthritis

Both the radial and the ulnar nerve must be discussed with the patient and deciduously avoided during the procedure.

Indication

The indication for this procedure is a loose body or modest osteophye formation. Note: It requires expertise.

Contraindication

The contraindications for this procedure are prior ulnar nerve translocation in the patient and limited experience on the part of the surgeon.

Open Joint Débridement

A “house cleaning” procedure has long been recommended for arthritic elbow disease.⁵⁰ A safe and effective débridement procedure was originally described by Outerbridge and popularized and first reported by Kashiwagi in 1978. Simply stated, this débridement procedure removes bone from the ulnar and humeral articular margins, altering the joint and justifying the term arthroplasty. Modification of this technique by exposure, and trephine débridement, descriptively termed ulnohumeral arthroplasty (UHA), is my preferred treatment for the selected patient.³⁸ Subsequently, there have been a number of articles from several sources documenting satisfactory outcomes of various débridement procedures. Most of these are termed the UHA, which is our preference or the O-K arthroplasty after the originators Outerbridge and Kashiwagi. I have also combined the UHA with the column procedure when an anterior débridement and capsular release is desirable (Fig. 76-7). In any event, Table 76-3 summarizes the outcomes of six studies comprising more than 160 patients.

FIGURE 76-7 The concept of the column procedure. The anterior and posterior capsules are released. The anterior and posterior osteophytes are removed.

TABLE 76-3 UHA: Summary of the Recent Literature Regarding the Intermediate Outcomes of Open Débridement for Osteoarthritis of the Elbow

Ulnohumeral Arthroplasty

Indications

The indications for UHA are extensive ulnohumeral osteophytes, capsular contracture, and impingement pain, especially with ulnar nerve symptoms.

Technique

The patient is placed in the supine position, with a sandbag under the scapula. The arm is prepped and draped to allow free motion and brought across the chest with the patient rotated about 35 degrees.

A straight incision 4 cm distal and 8 cm proximal to the olecranon is made over the posterior aspect of the elbow. A medial flap is elevated and the ulnar nerve decompressed in situ. We only rarely translocate the nerve in this circumstance.

The medial one half of the triceps attachment is elevated or the triceps is simply split in the mid line (Fig. 76-8).

FIGURE 76-8 Technique of ulnohumeral arthroplasty. The patient is supine and a straight incision is placed just medial to the olecranon. The ulnar nerve is inspected and decompressed if needed. The medial half of the triceps is reflected from the insertion on the olecranon. A, The tip of the olecranon is removed along with the olecranon osteophyte. The olecranon fossa is foraminectomized with a trephine. B, This crucial maneuver is made by following the contour of the trochlea and the trephine is oriented slightly proximal since the distal articulation of the humerus is anteriorly rotated. The humeral core is removed. C, The humerus is flexed, any anterior loose bodies that may be present are removed, and the osteophyte of the coronoid is removed with an osteotome through the foramen.

(By permission, Mayo Foundation, 1987.)

The tip of the olecranon and its osteophyte is removed. The olecranon fossa is opened with a trephine because this causes less debris and provides a more predictable and cleaner resection of the osteophytes than does a burr. The trephine is placed in the olecranon fossa with the curvature coincident with the concavity of the proximal aspect of the trochlea. The osteophytes, which are universally present in the olecranon fossa and which constitute an essential feature of the disease process, are removed, and the entire core of bone is removed from the olecranon to the coronoid fossa. This causes a through-and-through opening to the anterior joint.

Note: The placement of the trephine is worthy of emphasis. If the trephine is placed too distal, the competence of the trochlea may be impaired (Fig. 76-9); if it is placed too lateral, the capitellum may be violated; and if it is placed too medial, the medial column may be weakened.

FIGURE 76-9 Care should be taken to avoid too distal placement that will thin the trochlea (1), too medial displacement that may cause weakness of the medial column (2), or too lateral placement that can involve the capitellum on the anterior aspect (3).

(By permission, Mayo Foundation, 1987.)

The elbow is then flexed, and the coronoid osteophyte is brought into the foraminectomized coronoid fossa. A curved 7-mm osteotome is used to remove the anterior osteophyte from the coronoid. Any loose bodies are removed. The index finger is introduced through the defect, and the anterior compartment is inspected for any remaining loose bodies. A contracted anterior capsule can only be partially released. A Gelfoam sponge is rolled and placed in the defect of the foramen to avoid osteophyte recurrence.

If greater than 50% of the triceps has been detached, it is reattached with a nonabsorbable suture placed through bone, and the wound is closed.

I have yet to remove the radial head as an adjunct to this procedure and agree with Tsuge and Mizuseki⁵³ that this is to be avoided if at all possible.

Postoperative Management

The postsurgical treatment program is similar to that for those undergoing release for a post-traumatic stiff joint³³ (see Chapter 32). On the day of surgery, the patient is given a brachial plexus block with a constant infusion of local analgesic¹⁴ (see Chapter 8). The extremity is placed in a continuous motion machine and is elevated, and a passive arc of motion is aggressively established. The analgesic block is discontinued after approximately 24 hours, and continuous passive motion is monitored for a second day. Active motion is allowed to the greatest extent possible. A hinged splint is applied, and the patient is given detailed instructions with regard to the use of the splint to maintain both flexion and extension (see Chapter 11).³⁵

RESULTS

Minami et al³¹ updated the results of the original O-K arthroplasty in 44 elbows that were observed for 8 to 16 years. With a mean surveillance of more than 10 years, 55% had no or minimal pain. Appropriately, 10% deteriorated since the original report with a mean surveillance of about 5 years.³⁰ An additional 61% had partial relief of pain. Overall, 76% of patients had improved flexion and 55% had improved extension after surgery. With subsequent assessment, the mean arc had decreased to 32 to 122 degrees, representing a 17-degree loss over time (Fig. 76-10).

FIGURE 76-10 A, Anteroposterior roentgenogram of patient 3 months after ulnohumeral arthroplasty. B, After 3 years, some of the ectopic bone has re-formed in the fossa. Note osteophyte medially that was the source of ulnar nerve irritation. The result is rated as fair.

More recent reports are summarized in Table 76-3. Residual pain is present in about 15% of patients. Only a modest improvement in the arc of approximately 20 degrees of motion was observed. At a mean follow-up of 5 years, approximately 85% of patients were satisfied with the procedure. Furthermore, there has been one specific comparison of 18 patients with the open débridement and 26 patients undergoing arthroscopic joint débridement.⁶ At approximately 3 years’ follow-up, these investigators conclude interestingly that the pain relief seems to be superior after the arthroscopic procedure; however, at least in their hands, the postoperative arc of motion had increased more in the open than in the arthroscopic patients. We would conclude by saying that both techniques are viable, but the above-mentioned principles should be kept in mind for the arthroscopic intervention.

MAYO EXPERIENCE: ULNOHUMERAL ARTHROPLASTY

Initial results of Minami and Ishii parallel my preliminary and current experience.³⁸ Mansat et al²⁷ have reviewed the Mayo experience using this procedure in seven patients with osteoarthritis. A mean arc of 43 to 108 degrees improved postoperatively to 21 to 124 degrees, a 38-degree improvement. Pain relief was reliably achieved in all (Fig. 76-11). This technique can be an additional feature to the ulnohumeral débridement described below.

FIGURE 76-11 Typical features of primary elbow arthritis on the anteroposterior (A) and lateral (B) roentgenograms. Appearance 1 year (C) and 5 years (D) later.

RECENT UPDATE

In 2002 our experience with 46 elbows was reviewed by Antuna et al¹ with a mean follow-up of 80 months (2-14 years). It was documented that an improvement of 22 degrees occurred in the flexion arc, with an average arc at follow up of 30 to 135 degrees. Seventy-five percent of the elbows were not painful, reflecting the 75% that were considered satisfactory, a mean follow-up of 7 years. One major finding in this group was that the presence of ulnar nerve symptoms that was not addressed at the time of the débridement significantly and adversely affected the outcome. As a result of this experience, we have aggressively evaluated patients for the presence of ulnar neuropathy and have addressed this appropriately at the time of surgery.

Complications

If the technical points are understood and followed, the complication rate is very low, which is uncommon for most reconstructive procedures at the elbow. The ulnar nerve is at greatest risk. Recurrence of symptoms occur in 20% at 10 years.³¹ Recurrence of the radiographic changes may develop in as many as 50% of patients after 5 years.^19,20,29,30 (Fig. 76-12).

FIGURE 76-12 Redevelopment of osteophytes in the olecranon fossa and progression of osteophytes around the radial head are noted 15 years after ulnohumeral arthroplasty. The patient lost 10 degrees of extension and has recurrence of extension pain. An arthroscopic débridement was successful in relieving the patient of the posterior impingement pain.

EXTENDED DÉBRIDEMENT

In addition to the classic O-K or UHA, other authors have employed variations of an open débridement procedure.^42,56 If the patient is too young to undergo prosthetic replacement, an aggressive extensile débridement as recommended by Tsuge,⁵³ Oka,⁴¹ and others may be considered.

Procedure

Extensile Débridement (Tsuge Technique)

Indication.

The indications for extensile débridement include extensive hypertrophic changes, motion arc of less than 45 degrees, ulnar nerve symptoms, and age of younger than 65 years.

Technique.

This débridement is essentially that performed with interposition arthroplasty (see Chapter 69) but is limited to release and débridement.

The patient is supine, and a posterior incision is performed. The nerve is decompressed and the triceps reflected, generally from medial to lateral. We prefer notto release the ligaments but this is done by Tsuge (Fig. 76-13). The capsule is released, and the osteophytes are removed. The marginal osteophyte of the radial head is removed only if symptomatic. Removal of the entire radial head is avoided.

FIGURE 76-13 Extensile release described by Tsuge and associates.

Aftercare

The postoperative course is that of the ulnohumeral arthroplasty described earlier.

Results

Our experience is limited because the set of circumstances justifying this aggressive approach is uncommon. Approximately 80% have improved motion and relief of pain in our series. Tsuge reported improved motion and lessening of pain in most of the 29 patients at a mean of 64 months. The outcome of these procedures is very similar to that which is reported for the UHA, with satisfaction rates ranging from 85% to 95% at 5 to 10 years. The increase of motion averages around 20 to 25 degrees, and less than 10 percent of patients had residual pain.

Complications

The ulnar nerve can be symptomatic if not addressed. Tsuge reported a reoperation in two of 29 patients. Otherwise complications have been few.

ULNAR NERVE

PROSTHETIC REPLACEMENT

Kozak et al²⁴ reported our experience of five patients with primary osteoarthritis treated by joint replacement (Fig. 76-14). The mean age was 68 years. All five were doing well at final assessment, with a mean flexion arc of 30 to 125 degrees averaging 5 years after surgery. Yet, four had significant complications, such as fracture of the implant, ectopic bone, implant wear debris, and transient ulnar nerve symptoms. This topic is reviewed in detail in Chapter 60.

FIGURE 76-14 A, Severe hyptertrophic arthritis in a 67-year-old man. B, Three years after elbow replacement the patient has no pain but motion is only from 50 to 120 degrees (C). Note presence of ectopic bone.

Since the last edition, there have been few indications for replacement in our practice. Espag et al. did report 11 instances of primary degenerative arthritis treated by the Souter-Strathclyde implant with a mean surveillance of 68 months. Evidence of loosening was present in three humeral and two ulnar components, one of which was revised during the preparation of the manuscript. These authors also noted two neuropraxias of the ulnar nerve and overall believed that this was a satisfactory outcome in nine of the 11 cases.¹²