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

2. 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

3. 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%

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

6. Supracondylar Malunion: Late OA

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

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

9. 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

10. 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)

11. 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

13. 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

15. Rheumatoid Elbow

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

17. 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)

18. 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

19. 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

20. 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

21. Technique: O-K Procedure

23. 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

24. 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

25. 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

26. 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

29. 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

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

31. Technique

35. 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

36. 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

37. 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

38. 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

39. Arthrodesis of Elbow

41. 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

42. Supracondylar Malunion: Late OA

43. Re-alignment for OA: Osteotomy

44. 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

45. 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

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

47. Resurfacing Arthroplasty

49. Semi-constrained Elbow Arthroplasty

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

52. Surgical Technique

53. Surgical Technique
Ulnar nerve

54. Ulnar nerve, medial triceps peel

57. Broach humerus to correct height
Trial humerus in-situ

59. Burr entry to ulna
Broach ulna

60. Correct Ulnar Component Insertion

61. Assemble trial components
Trial insertion

63. Cement and Insert

64. Cemented insertion of pre-assembled final implant

65. Reattach triceps

66. Final x-rays

67. 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

68. 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%