Osteoarthritis of the Elbow Terry Axelrod MD MSc FRCS(C) Sunnybrook & Women’s University of Toronto

Primary Degenerative Arthritis Relatively uncommon Rarely mentioned in standard Orthopaedic texts Accounts for 1-2% of patients presenting with elbow arthritis Less than 5% of elbow replacements performed on individuals with a diagnosis of primary elbow Osteoarthritis

Demographics: Males > females Average age at presentation 50 years Other risk factors: Paralysis or Neuropathic conditions requiring wheelchair or crutch ambulation Occupations: repetitive use Dominant extremity in 80-90% individuals Bilateral involvement in 25 –60%

Other causes of elbow OA Non-primary: Septic Neuropathic (Charcot) Post-traumatic (intra-articular) Post-Dislocation (reduced or not) Deformity related (extra-articular )

Supracondylar Malunion: Late OA

Clinical Presentation Most common complaint: loss of motion Terminal extension loss in almost all

Clinical Presentation: Pain: mild to moderate Usually at terminal extension with use Occurs in 50% with full flexion Other presentations: Swelling Deformity Cosmesis

Physical Examination Bony deformity Elbow effusion Local tenderness Reduced range of motion: Typically range 30 – 120 average pronation and supination not usually affected until late Ulnar nerve may be compromised 2nd to osteophyte formation posterior-medially

Radiographic Investigations Plain x-rays with ap, lateral and obliques are usually sufficient CT scan if diagnosis difficult to make CT , air contrast arthrogram may be occasionally useful for cartilagenous loose bodies MRI also good for loose bodies and definition of extent of OA (rarely needed)

Radiographic Features: Anterior osteophyte on the coronoid and posterior on the olecranon process Radial head deformity with osteophyte formation in ~ 50% Loose bodies in ~ 50% Other classical OA features Joint narrowing Subchondral sclerosis Angular deformity

Radiographic Features: Anterior osteophyte on the coronoid and posterior on the olecranon process Radial head deformity with osteophyte formation in ~ 50% Loose bodies in ~ 50% Other classical OA features Joint narrowing Subchondral sclerosis Angular deformity

Rheumatoid Elbow

Treatment Options Operative and non-operative Non-operative: Physiotherapy Intra-articular injections: Steroids Lubricants (Syn-Visc etc.) Bracing: Static Dynamic (Dynasplint, turn-buckle splint)

Treatment Options: Operative As with any arthritic joint you can: Debride the joint Realign the joint Resect and/or resurface the joint Arthrodese the joint Replace the joint (Total Joint Arthroplasty)

Treatment Options: Operative Minimally to maximally invasive Arthroscopy O’Driscoll and Morrey JBJS 1992 Of little value in OA Indication: loose bodies with mechanical symptoms

Operative Joint Debridement Lateral, posterior or anterior approach “House cleaning” with resection of osteophytes, scar tissue, adhesions, capsular release No resurfacing done Posterior approach through bone can be termed: Humeral-Ulnar Arthroplasty

Humeral-Ulnar Arthroplasty First described by Kashiwagi 1978 Jpn Orthopaedic Association Journal Modified by Outerbridge 1986 Posterior triceps split approach to the elbow Resection of the tip of the olecranon, trephine out the fossa and do the anterior debridement through the fossa

Technique: O-K Procedure

O-K Procedure Post-operative Protocol Results: Early active and passive ROM Flexion and extension adjustable splints are needed Results: Minami and Ishii Reported on 111 elbows 0.5 to 11 years Males >> females

O-K Procedure: Results Minami and Ishii 1986 Reported on 111 elbows 0.5 to 11 years Males >> females 39% complete pain relief 21% pain during motion reduced 61% partial relief 55% improved extension, 76% improved flexion

O-K Procedure: Results Morrey 1993 Small series 15 patients, 2 year follow-up Flexion improved 8 degrees, extension 12 degrees 86% subjectively satisfied with procedure 13 of 15 improved by one grade in terms of subjective scoring with the Mayo Elbow Score

Lateral Debridement Same concept as O-K procedure Done through a lateral Kocher approach Allows better anterior debridement Allows full anterior capsular release Allows access to posterior joint Allows radial head excision or Arthroplasty Author’s preferred method

Interposition Arthroplasty Fascia Lata or Skin is Interposed between the Humerus and Ulna after osteophyte resection and joint debridement Can be enhanced by use of distraction hinge such as the Compass Hinge External Fixator

General Indications For more advanced OA elbow following: Trauma Burns Sepsis Degenerative OA Resulting in severe pain and/or loss of motion

Technique

Post-operative care Bracing and dynamic splintage are needed Rehab is very difficult and protracted Results indicate improvement over two years post-operative Old publications, results not adequately studied

Fascial Arthroplasty of Elbow OA Authors experience: Very limited indications for use Burns Severe soft tissue contractures Young individual, laboring occupation with advanced OA Results are modest at best, however often there is no viable alternative May be improved with use of compass hinge distraction

Arthrodesis for Elbow OA Generally not considered as an elbow arthrodesis is a severe functional impairment Indications are few: Severe bone loss, soft tissue loss in young individual, Arthroplasty is contraindicated Failed Total Elbow Arthroplasty Sepsis

Elbow Arthrodesis Surgical technique Posterior exposure Identify and protect ulnar and radial nerves Arthrotomy, debride joint surfaces, excise radial head Temporarily fix position with K wires Lag screws across humeral-Ulnar joint surface Long plate: position of fusion? Bone graft

Arthrodesis of Elbow

Realignment for Osteoarthritis Rarely indicated for OA, usually for impaired appearance or function or tardy Ulnar nerve palsy However, like any joint, altered mechanics can result in eccentric wear and then OA Realignment does play a role in these cases

Supracondylar Malunion: Late OA

Re-alignment for OA: Osteotomy

Total Elbow Arthroplasty for OA Indications are similar to other joints however: Younger age group with OA of the elbow Higher functional demands, implant longevity issues Range of motion is less than with RA Indicated mainly for pain relief and functional limitations Age > 60 years generally accepted

Total Elbow Arthroplasty Limitations post surgery are significant and thus impact on indications for surgery and patient selection Life-long restriction of weight lifting to 5 lbs maximum Avoid torque, thus golf and racquet sports

Options for Total Elbow Arthroplasty Resurfacing Capitello-condylar Souter-Strathclyde Pritchard and others Semi-constrained Mayo-Coonrad (Coonrad-Morrey) Triaxial Arizona

Resurfacing Arthroplasty

Semi-constrained Elbow Arthroplasty

The Evolution of the Idea of Arthroplasty in the Elbow Coonrad and Morrey developed the semi-constrained “hinge” elbow arthroplasty

Surgical Technique

Surgical Technique Ulnar nerve

Ulnar nerve, medial triceps peel

Broach humerus to correct height Trial humerus in-situ

Burr entry to ulna Broach ulna

Correct Ulnar Component Insertion

Assemble trial components Trial insertion

Cement and Insert

Cemented insertion of pre-assembled final implant

Reattach triceps

Final x-rays

Results TEA for OA Elbow Little in literature for primary OA, lots on RA; Not the same and should not compare Resurfacing seems to be poor for OA Dislocation rates approach 30% at 5 years on survivorship analysis Loosening, supracondylar fractures relatively common on the humeral side

Results TEA for OA Elbow Morrey JBJS 1991 reported on 54 TEA for post-traumatic OA of the elbow F/U 6 years Re-operation rate of 13% Revision rate of 5% at 3 years Progressive lucent lines 20% Overall satisfactory rate of 90%