ARTHRITIS
Primary osteoarthritis of the
elbow is uncommon, unlike in the hip and knee; and the need for joint
replacement in the elbow is much less common than the hip, knee, and shoulder.
Elbow arthritis often develops in patients who repetitively load the joint,
such as heavy laborers or athletes. It more commonly occurs in males and in the
dominant extremity. Symptoms typically include pain and loss of motion. Pain
typically occurs at the end ranges of motion, particularly terminal extension,
from impingement due to osteophytes. Pain through the midrange of elbow motion
is much less common but may develop if the articular cartilage loss is severe
enough.
Other common causes of elbow
arthritis include inflammatory conditions, most commonly rheumatoid arthritis,
and trauma, most commonly after an intra-articular fracture. The elbow is a
common site of involvement in rheumatoid arthritis, but the pharmacologic
advances in treatment of this disease have made the progression of arthritis
and symptoms much less severe. Although advances in implants have helped in the
surgical treatment of intra-articular elbow fractures, post-traumatic arthritis
can still occur.
Nonoperative management of
elbow arthritis is the initial treatment and includes activity modification,
range-of-motion exercises, use of braces and other support devices,
intra-articular cortisone injections, and administration of nonsteroidal
anti-inflammatory drugs or disease-modifying antirheumatic drugs.
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| IMAGING OF OPEN AND ARTHROSCOPIC ELBOW DEBRIDEMENT |
Initial surgical treatments
for elbow arthritis include open or arthroscopic debridement procedures (see Plate 2-33). These surgeries
are done to improve pain and range of motion, and may include removal of loose
bodies, osteophyte resection, capsular release or excision, and synovectomy.
Recovery time can be shorter after an arthroscopic debridement, but there is a
potential risk of neurovascular injury with this technique.
This risk is particularly
increased in patients who have undergone prior surgery in the elbow, owing to
the distortion of normal anatomy. In osteoarthritis, osteophytes commonly form
at the tip of the olecranon and the olecranon fossa and at the tip of the
coronoid and the coronoid fossa. These bone spurs can cause impingement-type
pain at the end ranges of motion, and their removal can help relieve such
symptoms.
Synovitis is a common source
of pain and limited motion in a patient with rheumatoid arthritis; there fore,
surgical synovectomy can be beneficial and may also prevent further destruction
of cartilage and bone. Finally, ulnar nerve symptoms may develop in an
arthritic elbow with significant loss of range of motion, and thus ulnar nerve
decompression or transposition is recommended in combination with the
debridement procedure in such situations.
Although debridement
procedures can provide significant symptom relief, they may not be as
beneficial in patients with more advanced arthritis and their effect may wear
off over time as the arthritis progresses. In these instances, surgery is aimed
at reconstruction of the diseased elbow joint. Most commonly, this is in the
form of a total elbow replacement, but other techniques have occasionally been
employed, including interpositional arthroplasty, resection arthroplasty, and
elbow arthrodesis. Interpositional arthroplasty may be an option in younger
patients with severe arthritis, who may be too active for consideration of a
total elbow replacement. The procedure involves covering the diseased joint
surfaces with a biologic material (e.g., autogenous fascia lata, dermal
allograft) to improve pain and range of motion (see Plate 2-34). Resection arthroplasty is not
commonly used today as a primary treatment for arthritis because of the
resultant instability and dysfunction at the elbow after this procedure,
although bony ankylosis can occur. It is primarily considered as a salvage
procedure in cases of failed prior surgery and intractable infection. Elbow
arthrodesis is also rarely used currently, because fusion in a single position
can be difficult for reasonable upper extremity function. It can be considered
a salvage procedure in cases of infection and may rarely be considered an
option in a young heavy laborer who may place too high a demand on an elbow
replacement.
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| ELBOW ARTHOPLASTY OPTIONS |
Severe, disabling arthritis is
best treated with total elbow arthroplasty. Total joint replacement restores
joint motion and relieves pain by replacing the diseased articular surfaces
with a plastic and metal prosthesis. The typical implant is an ulnohumeral
arthroplasty, with a stemmed, metallic humeral implant and a stemmed, metallic
ulnar implant that articulate through a
polyethylene-bearing surface (see Plate 2-34). Both linked and unlinked
prosthetic designs are available. Linked implants directly connect the humeral
and ulnar components through the bearing surface and are indicated in patients
with excessive bone destruction and/ or ligamentous destruction or instability.
The hinge mechanism can be classified as constrained or semiconstrained on the
basis of the absence or presence of side-to-side laxity in the implant. Modern
linked designs have a semiconstrained articulation that allows some
side-to-side laxity, in order to decrease stress across the implant and lower
the rate of component loosening (see Plate 2-35). Unlinked prostheses have no direct
connection between the humeral and ulnar components and, therefore, require the
presence of adequate bone stock and intact or reconstructed collateral
ligaments (see Plate 2-35).
If functional collateral ligaments are not present, implant failure can occur
due to instability.
The most common complication
of total elbow arthroplasty and the one that causes the most concern over time
is implant loosening and resultant instability. Implant survival rates vary
depending on the etiology of the underlying arthritis, with survival rates as
high as 94% at 15 years in rheumatoid arthritis patients but as low as 70% at
15 years in the post-traumatic population. This discrepancy is due in part to
differences in age and activity level, with patients undergoing total elbow
replacement for post-traumatic arthritis usually of a much younger age and/or
higher activity level than rheumatoid arthritis patients.
Arthritic changes at the
radiocapitellar joint may also need to be treated with joint replacement,
either in isolation or in combination with total elbow arthroplasty. This is
most commonly addressed with radial head resection or replacement (see Plate
2-25). Whereas resection of the radial head alone can provide pain relief, over
time it may lead to proximal displacement of the radial shaft if the
interosseous membrane and distal radioulnar joint are or become deficient.
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| IMAGING OF TOTAL ELBOW ARTHROPLASTY DESIGNS |
Proximal radial migration can
cause pain and dysfunction, particularly with pronation-supination movements.
These complications can be avoided by using a radial head replacement.
Traditional implants were made of silicone, but this material has been replaced
by metallic prostheses because of the high complication rate noted with
silicone, particularly the generation of a signi cant inflammatory response
from particulate debris.
