Osteoarthritis & Stiffness

Elbow OA

 

Epidemiology

 

Relatively rare

Average age 50

Men 4:1 Women

Usually dominant arm

 

Aetiology

 

Primary

- rare

- 2% of all cases

- associated with heavy manual labour

 

Secondary

- trauma - intra-articular distal humerus fractures

- capitella OCD

- synovial chondromatosis

- repetitive athletic overuse

 

Pathology

 

Begins radiocapitellar joint and progresses to ulnohumeral joint

 

Forces across joint about 1/2 body weight

- increased in strenuous work

- small cross sectional area

- increases contact stresses

 

Symptoms

 

Stiffness

 

End range pain

- minimal in mid range

- pain when olecranon and coronoid osteophytes impinge

 

Progress to pain throughout entire range in end stage of disease

 

Functional range

- 100 degrees flexion extension arc (30 - 130)

- 100 degrees forearm rotation (50 degrees supination and 50 degrees pronation)

 

X-ray

 

Early stage

- preserved radiocapitellar and ulnohumeral joints

- osteophytes of the olecranon and coronoid

 

Elbow OA LateralElbow OA AP

Lateral xray demonstrating olecranon and coranoid osteophytes

 

CT

 

Define antomy pre operation

Identification loose bodies

 

Elbow Arthritis CTElbow OA sagittal CT

Osteophyte of the olecranon likely impinging in extension

 

Elbow Loose Bodies CTElbow Loose Bodies CT 2

CT demonstrating loose bodies in the ulnohumeral joint

 

3D CT elbow OA 13D elbow CT OA 2

Multiple loose bodies in anterior and posterior elbow joint

 

MRI

 

Useful in detecting early chondral damage

 

MRI Radiocapitellar OAMRI Ulna Trochlea OA

MRI chondral damage radiocapitella joint     Chondral thinning ulnohumeral joint

 

MRI elbow OA

Chondral changes in the radiocapitellar and ulnohumeral joint

 

Arthroscopy

 

Capitellar Chondral InjuryRadial Head Chondral DamageUlna Chondral Damage

Chondral damage capitellum                          Chondral damage radial head                           Chondral damage ulnohumeral joint       

 

DDx

 

Inflammatory arthritis / Rheumatoid arthritis

- minimal osteophytes

- severely arthritic joint spaces

- have pain throughout range of motion

 

Elbow RA 1Elbow RA 2

 

Management

 

Non operative

 

Analgesia

Injections

 

Injections

 

Limited evidence

 

Technique

 

Soft spot

- lateral approach

- triangle of lateral epicondyle / lateral olecranon / radial head

 

Kim et al J Clin Ultrasound 2013

- 40/40 injections intra-articular with ultrasound guidance

- 31/40 injections intra-articular with palpation guidance

 

Results

 

Van Brackel et al Arthroscopy 2006

- 18 patients treated with 3 injections of hyaluronic acid

- some pain relief at 3 months, none at 6 months

 

Operative

 

Options

 

Open debridement

Outerbridge-Kashiwagi (OK) procedure

Arthroscopic debridement

Interposition arthroplasty

Total elbow arthroplasty

 

Open Debridement

 

Goals

 

Remove coracoid and olecranon osteophytes

Capsular releases

 

Approach

 

Universal posterior approach

 

Lateral interval

- distal humeral: elevating BR and ECRL

- distal: between ECRB and EDC

 

Medial interval

- find and protect ulna nerve

- proximal: between triceps and brachialis

- distal: detach pronator teres

 

Technique Morrey

 

A.  Muscle releases

- brachialis released from humerus

- triceps released from humerus

B.  Capsulotomy / capsulectomy

- anteriorly elevate brachialis off capsule

C.  Excision of HO

D.  Removal of osteophytes

- coronoid / olecranon 

E.  Debridement of osteochondral flaps / loose bodies

F.  +/- Release of collateral ligaments

- preserve anterior band of MCL 

- ligament reconstruction & hinged elbow fixator if becomes unstable

G.  +/- Radial head debridement / excision

 

Outerbridge-Kashiwagi (OK) procedure

 

Concept

 

Posterior approach

- drill hole in distal humerus

- allows access to coranoid process for debridement

 

Elbow OK Procedure LateralElbow OK Procedure AP

 

Technique

 

Vumedi Outerbridge Kashiwagi (OK) procedure surgical technique

 

Posterior approach and triceps split

- excision of posterior capsule

- excision of tip of olecranon

 

Access to anterior compartment via olecranon fossa

- 1 cm diameter hole

- debridement of coranoid +/- radial head

- removal of loose bodies

 

Results

 

Tat et al JSES 2022

- 178 OK procedures

- survivorship with total elbow arthroplasty as end point

- 100.0% at 1 year

- 98.8% at 5 years

- 98.0% at 10 years

 

Arthroscopic Debridement

 

Relative Contra-indications

- previous ulna nerve transposition

- severe soft tissue contractures

- bridging HO

 

Technique

 

Elbow osteoarthritis arthroscopic debridement surgical technique PDF

 

Vumedi arthroscopic debridement elbow arthroscopy

 

Anterior joint

- remove loose bodies

- resect coronoid osteophytes

- anterior capsular release to improve extension

- +/- radial head resection

 

Posterior joint

- remove loose bodies

- resect olecranon osteophytes

 

Results

 

White et al Arthroscopy 2021

- systematic review of open versus arthroscopic debridement elbow OA

- no difference in ROM improvement / outcome measures / complications

 

Sochacki et al Arthroscopy 2017

- systematic review of arthroscopic debridement for elbow OA

- 9 articles and 213 elbows

- evidence of improved ROM and outcome scores with low complication

 

Carlier et al Orthop Traumatol Surg Res 2019

- prospective study of 87 patients

- significant improvements in pain, ROM and strength

- radial head resection did not improve outcomes

 

Case

 

Post elbow fracture malunion / posterior impingement / FFD 40o

 

Elbow Malunion LateralElbow Malunion MRI

 

Elbow Malunion ImpingementElbow Malunion Impingement

Posterior elbow arthroscopy, with arrows pointing to olecronon tip on the right in the flexed and extended position

 

Elbow Malunion Partial DebridementElbow Malunion Post Debridement

Post debridement of the tip of the olecranon, in the flexed and extended elbow position

 

Elbow Malunion PreopElbow Malunion Post Op

Elbow extension pre and post arthroscopic debridement

 

Interpositional arthroplasty

 

Technique

 

Vumedi elbow interpositional arthroplasty video

 

Elbow interposition arthroplasty surgical technique PDF

 

Strip of fascia lata / achilles tendon allograft

- graft passed around end of humerus to cloth front and back

 

+/- hinged external fixation with distraction

 

Results

 

Lanzerath et al Int Orthop 2022

- systematic review of 5 studies and 67 patients

- 21% revision rate

 

Total elbow arthroplasty (TEA)

 

Indications

- > 65

- sedentary

 

Results

 

TEA uncommonly required for primary OA

? reduced long term survival compared to RA

 

Viveen et al Acta Orthop 2019

- 1220 TEA from Australian Joint Registry

- percentage revision was 10%, 15%, and 19% at 3, 6, and 9 years

- revision rate for OA > trauma and RA

 

Schoch et al JSES 2017

- 20 TEA for primary elbow OA with mean 9 years follow up

- 3 mechanical failures

- no improvement in extension