Ulnohumeral (Outerbridge-Kashiwagi) Arthroplasty
DEFINITION
Primary osteoarthritis of the elbow is a relatively uncommon but disabling disorder that affects mostly middle-aged men who use the upper extremity in a repetitive fashion. Typically, patients are heavy manual workers or athletes. Osteoarthritis affects the elbow less frequently than other major joints.
Early stages of arthritis of the elbow may be characterized primarily by pain at the extremes of motion, with some loss of terminal extension and flexion. Some patients present with pain carrying an object with the arm in extension. More advanced stages may present with pain and crepitus throughout the range of motion, stiffness, or locking. Rotation of the forearm may be spared, depending on radiocapitellar involvement.
Radiographs show osteophyte formation on the coronoid and olecranon but relatively preserved joint space at the early stages. More advanced stages may be associated with significant joint space narrowing.
Multiple operative techniques have been described for treatment of primary osteoarthritis of the elbow: débridement arthroplasty, interposition arthroplasty, the Outerbridge-Kashiwagi procedure, arthroscopic débridement, and total elbow replacement.
Ulnohumeral (Outerbridge-Kashiwagi) arthroplasty was first described in 1978 and became popular a few years later. It is based on a posterior approach to the elbow, removal of any olecranon spur and bony overgrowth of the olecranon fossa, trephination of the fossa to expose the anterior capsule, and excision of the coronoid osteophyte.
Recent advancements allow the procedure to be performed with arthroscopic fenestration of the olecranon fossa, débridement, and removal of loose bodies.
ANATOMY
The elbow joint consists of three separate articulations: the ulnohumeral, the radiocapitellar, and the proximal radioulnar joints.
The elbow has two main functions: to position the hand in space and to stabilize the upper extremity for motor activities and power.
The normal range of elbow flexion-extension is 0 to 150 degrees, whereas normal forearm pronation-supination is 80 degrees of each.
A 100-degree flexion-extension arc of motion (30 to 130 degrees) is required for normal activities of daily living. Functional forearm rotation is quoted as 100 degrees (50 degrees pronation and 50 degrees supination).
The condyles articulate at the elbow joint, as the trochlea medially and the capitellum laterally. The articular surface is titled about 30 degrees anterior to the axis of the humeral shaft and aligns in approximately 6 degrees of valgus.
The coronoid fossa and the olecranon fossa, just proximal to the articular surface, accommodate the coronoid process and olecranon process of the ulna in the extremes of flexion and extension, respectively.
The olecranon and coronoid process coalesce to form the greater sigmoid notch, the main articulating portion of the proximal ulna. It is often not completely covered with articular cartilage centrally.
PATHOGENESIS
Symptomatic osteoarthritis of the elbow has been found to affect about 2% of the general population and represents only 1% to 2% of all patients diagnosed with degenerative arthritis.
It has a predilection for males, with a ratio of 4:1 or 5:1. It is most commonly seen in middle-aged and older patients.
The majority of patients experience symptoms in their dominant extremity.
The exact etiology of primary degenerative elbow arthritis is still unknown. It is generally attributed to overuse. About 60% of patients report employment or hobbies/sports requiring repetitive use of the limb. The few younger patients who present likely have a predisposing condition such as osteochondritis dissecans.
There are characteristic pathologic changes that occur within the elbow joint: osteophyte formation on the olecranon, olecranon fossa, coronoid, and coronoid fossa.
In early stages, the joint space is relatively well preserved. The periarticular bone is typically sclerotic. Loose bodies frequently develop within the joint causing clicking or locking of the elbow.
Capsular fibrosis and contracture of the anterior capsule contribute to loss of extension.
NATURAL HISTORY
Early stages of primary osteoarthritis of the elbow are characterized by pain at the extremes of motion and some loss of terminal extension and flexion. As the severity of the arthritis progresses, pain and stiffness increase.
Surgical intervention is indicated when symptoms do not improve with nonoperative management.
As osteoarthritis is a progressive disease, symptoms may recur over time, typically in the form of impingement pain and flexion contracture.
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Prognostic factors include the etiology of arthritis, the degree of motion loss, mid-arc versus end-range
discomfort, the presence of loose bodies, mechanical symptoms, and the presence or absence of cubital tunnel syndrome.
PATIENT HISTORY AND PHYSICAL FINDINGS
The typical patient with primary degenerative elbow arthritis is a man older than 45 years of age, exposed to repetitive manual labor, and presenting with pain at the end ranges of motion, especially in extension.
Younger patients may provide a history of sports such as weightlifting, boxing, and other throwing-intensive activities. Arthritic elbows in athletes frequently will include a spectrum of pathologic changes, such as loose bodies and bone spurs.
Some patients report a history of chronic use of crutches or a wheelchair.
The chief complaint is pain, especially in terminal extension as a result of mechanical impingement. Patients usually hurt while carrying objects with the elbow in full extension.
The intensity of pain is mild to moderate and only occasionally is described as severe. Pain is usually not noted in the midrange of motion until later stages of arthritis.
Loss of motion is another common presenting symptom.
Loss of extension is often the result of posterior olecranon and humeral osteophytes and/or anterior capsule contracture.
Loss of flexion is secondary to osteophytes on the coronoid or its fossa and/or loose bodies.
Supination-pronation is preserved or is only minimally restricted, owing to limited involvement of the radiocapitellar joint.
Catching or locking may be present with articular incongruity or when loose bodies are present. Crepitus may be present throughout the range of motion.
Swelling may occur but is not typical.
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FIG 1 • A. Lateral radiograph of a 50-year-old heavy laborer's elbow. The patient had severe pain at the extremes of motion. The radiograph reveals characteristic osteophytes of the olecranon and of the coronoid process. B. AP radiograph of the elbow (same patient). This view shows ossification and osteophytes of the olecranon and coronoid fossa. C. Lateral oblique radiograph. This view provides better visualization of the radiocapitellar and radioulnar joint. There is an osteophyte at the tip of the olecranon, which causes pain during full extension.
Ulnar nerve symptoms may also be present, owing to excessive osteophyte formation. They should actively be sought out because they may influence treatment decisions and even direct the surgical approach.
Physical examination may reveal a positive Tinel sign and a positive elbow flexion test, with decreased sensation and weakness in the ulnar nerve distribution. Cubital tunnel syndrome may be present in up to 20% of patients.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Anteroposterior (AP), lateral, and oblique radiographs (FIG 1) are diagnostic and illustrate characteristic features of the condition.
The AP view should be taken with the beam perpendicular to the distal humerus for distal humerus pathology and perpendicular to the radial head for proximal forearm pathology. These views will show ossification and osteophyte formation of the olecranon and coronoid fossae.
The lateral view should be taken in 90 degrees of flexion with the forearm in neutral rotation. This view will show an anterior osteophyte on the coronoid fossa and process and a posterior osteophyte on the olecranon fossa and process.
The lateral oblique view provides better visualization of the radiocapitellar joint, medial epicondyle, and radioulnar joint.
The medial oblique view provides better visualization of the trochlea, olecranon fossa, and coronoid tip. A cubital tunnel view may be useful if there is ulnar nerve symptomatology.
Computed tomography or a lateral tomogram are helpful for preoperative planning to assess the presence and location of loose bodies and subtle osteophyte formation (especially in earlier stages).
DIFFERENTIAL DIAGNOSIS
Posttraumatic arthritis
Rheumatoid (inflammatory) arthritis
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NONOPERATIVE MANAGEMENT
Nonoperative treatment may be helpful in early stages. Patients should limit activities that require heavy elbow use.
Physical therapy is used to maintain range of motion and strength. Modalities such as heat and cold may be effective.
Nonsteroidal anti-inflammatory drugs can decrease pain and are of some value. Intra-articular corticosteroid injections may also improve symptoms, but their benefits are usually temporary.
Avoidance of pressure on the cubital tunnel and avoidance of prolonged elbow flexion are recommended if ulnar nerve symptoms are present.
SURGICAL MANAGEMENT
Surgical treatment is indicated when symptoms do not improve with appropriate nonoperative management.
The procedure is indicated in patients with pain in terminal extension or flexion (or both), radiographic evidence of coronoid or olecranon osteophytes (or both), ulnar neuropathy, and functional limitations due to pain or loss of motion.
The procedure is contraindicated in patients with pain throughout the entire arc of motion, marked limitation of motion with an arc of less than 40 degrees, or severe involvement of the radiocapitellar or proximal radioulnar joints.
The arthroscopic technique is relatively contraindicated in patients with previous elbow trauma or ulnar nerve
transposition because of altered anatomy and potential risk of injury to adjacent neurovascular structures.
Preoperative Planning
It is very important to carefully review all radiographs (AP, lateral, oblique) before surgery to assess the severity of arthritic changes and evaluate for the presence of loose bodies. Computed tomography may assist in this evaluation. Care should be taken not to overlook any loose bodies, as these may lead to persistent mechanical symptoms postoperatively.
Specific attention should be paid to the presence of ulnar nerve pathology. If present, this must be addressed at the time of the procedure.
Positioning
Open or arthroscopic technique
The patient is placed in the lateral decubitus position with the elbow flexed at 90 degrees and resting on an armrest.
Open technique
Alternatively, the patient may be placed supine with a sandbag underneath the scapula. The elbow is flexed at 90 degrees and brought across the chest. The patient is rotated about 35 degrees for better access to the posterior aspect of the affected elbow.
APPROACH
Open technique
A posterior approach is used. The incision is longitudinal, starting 6 to 8 cm proximal to the tip of the olecranon and extending 4 cm distal to the olecranon (FIG 2).
Dissection is carried down to the triceps fascia.
The triceps tendon can be split or reflected. In the original description, the triceps muscle is split along the midline, exposing the posterior aspect of the elbow to the lateral and medial supracondylar ridges.
Alternatively, the medial margin of the triceps tendon may be reflected from the olecranon.
The decision to reflect or to split the tendon is determined based on the size of the distal aspect of the triceps and the need to explore and decompress the ulnar nerve. If the muscle is very bulky, reflection will not provide adequate exposure.
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FIG 2 • With the patient in the lateral decubitus position, the elbow is flexed at 90 degrees and is resting on pillows (authors' preferred method). A posterior approach is used via a longitudinal skin incision, which extends distally about 4 cm and proximally 6 to 8 cm from the tip of the olecranon. Note the marked medial epicondyle.
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TECHNIQUES
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Open Humeral Arthroplasty
Exposure
After skin incision, the subcutaneous tissue is reflected from the medial aspect of the triceps.
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TECH FIG 1 • The triceps muscle has been split to expose the posterior joint. The prominent olecranon osteophyte and the tip of the olecranon process are then removed. The initial cut should be made with an oscillating saw to provide optimal orientation. The osteotomy of the olecranon is completed with an osteotome parallel to each facet of the trochlea.
The ulnar nerve is identified and decompressed at the cubital tunnel if there is evidence of ulnar nerve pathology.
The triceps muscle-tendon unit is split longitudinally or reflected.
The triceps is elevated from the posterior aspect of the distal humerus by blunt dissection using a periosteal elevator.
A capsulotomy is then performed (TECH FIG 1).
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Osteophyte Removal and Olecranon Resection
To minimize impingement in extension, the posterior osteophyte and the tip of the olecranon are removed using an oscillating saw. An osteotome is then used to complete the resection. The orientation of the osteotomy should be parallel to each facet of the trochlea.
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TECH FIG 2 • A neurosurgical dowel is used to make a hole and remove the ossified olecranon fossa. Care should be taken for proper placement of the foraminectomy. The dowel should follow the curvature of the trochlea.
A rongeur is used to smooth the edges.
A hole is drilled in the olecranon fossa to gain access to the anterior elbow compartment and the coronoid process. This requires removal of osteophytes around the olecranon fossa (TECH FIG 2).
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Foraminectomy
A 1.5-cm neurosurgical dowel is applied to a reaming drill bit, and a drill hole is developed. Proper
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placement of this foraminectomy is of great importance. The dowel should follow the curvature of the trochlea.
Once the foraminectomy is complete, a core of bone is removed from the distal humerus. This may include osteophytes from the anterior aspect of the joint (TECH FIG 3A,B).
This hole is used to clean debris and remove loose bodies from the anterior aspect of the elbow (TECH FIG 3C,D).
With maximum elbow flexion, the anterior osteophyte from the coronoid process is removed using a curved osteotome.
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TECH FIG 3 • A,B. Once the foraminectomy is completed, the core of bone is removed from the distal humerus. This allows access to the anterior elbow compartment and to the coronoid. At this time, loose bodies of the anterior compartment may be identified and removed. C. With maximum elbow flexion, the anterior osteophyte from the coronoid process is removed, using a curved osteotome. D. An instrument is then introduced through the foramen, and the osteophyte and a portion of the coronoid are removed.
Occasionally, it is necessary to strip the anterior capsule from the anterior humerus using a blunt periosteal elevator to restore extension.
Care must be taken to ensure that no osteophytes or loose bodies are overlooked.
Bone wax is used to cover the margins of the foramen, and Gelfoam is inserted into the defect to fill the dead space.
The wound is meticulously irrigated and closed in standard fashion. The elbow is carefully manipulated to maximize the total arc of motion.
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Arthroscopic Ulnohumeral Arthroplasty
The elbow joint is insufflated with 15 to 20 mL of normal saline to distend the capsule of the joint.
An anterolateral portal is established proximally to radiocapitellar joint and anteriorly to the lateral supracondylar ridge of the distal humerus.
The arthroscope is introduced through the anterolateral portal allowing visualization of any pathologic structures of the anterior compartment of the joint and then an anteromedial portal is established.
Removal of loose bodies and débridement of the anterior aspect of the elbow can be performed using an arthroscopic grasper and an arthroscopic shaver.
The posterior aspect of the elbow is then palpated, and a standard posterolateral and posterior central portal are established.
Débridement of spurs from the olecranon fossa and removal of loose bodies of the posterior aspect of the elbow can be performed through the posterior central portal.
A 3.2-mm drill is then inserted through the posterior central portal into the center of the olecranon fossa and is angled toward to the center of the coronoid fossa. A drill hole is then developed from posterior to anterior to fenestrate the olecranon fossa.
Under arthroscopic visualization through the anterolateral portal, the drill hole is enlarged in diameter to at least 1 cm using progressively larger drill bits.
Once the foraminectomy of the olecranon fossa is complete, removal of the osteophyte from the coronoid process can be performed with maximum elbow flexion using an arthroscopic burr.
All incisions are closed in standard fashion.
PEARLS AND PITFALLS
Indications
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Primary osteoarthritis of the elbow presenting with pain at the extremes of
motion due to osteophyte formation on the olecranon or coronoid process (or both) and in the olecranon or coronoid fossa (or both)
Contraindications ▪ Severe involvement of the radiocapitellar joint
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Pain throughout the entire arc of motion
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Previous elbow trauma or ulnar nerve transposition are relative contraindications for arthroscopic technique.
Assessment
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Careful selection of patients is important.
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Appropriate imaging studies should be obtained to identify all loose bodies or osteophytes. Computed tomography may be indicated.
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The surgeon should always evaluate for coexisting ulnar nerve pathology, which should be addressed during surgery.
Operation
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Proper placement of foraminectomy
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Meticulous inspection of posterior and anterior aspects of the joint
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Removal of all loose bodies and osteophytes
POSTOPERATIVE CARE
A splint is applied with the elbow in relative extension (15 degrees) for 1 week. Active range of motion is allowed 7 to 10 days after surgery.
The patient is reevaluated at 3 weeks, 6 weeks, and 3 months after surgery.
Continuous passive motion can be initiated on the day of surgery and is discontinued after 3 weeks.
Sports activities are permitted after 6 weeks to avoid a potential fracture due to the biomechanical weakening of the columns.5
OUTCOMES
A review of the literature shows satisfactory results in over 80% of patients with open or arthroscopic technique.1,3,4,6,8,9,10,11,12,13,14,15,16,17,18,19,20
Satisfactory pain relief is achieved in about 90% of patients with both techniques.1,3,4,6,8,9,10,11,12,13,14,15,16,17,18,19,20
Extension improves by about 10 to 15 degrees, and flexion improves by about 10 degrees. Overall improvement in the motion arc is about 20 to 25 degrees (FIG 3).
Comparative studies between the open and arthroscopic techniques demonstrated no statistically
significant difference in overall effectiveness.3,4 Higher gain in elbow flexion was achieved with the open procedure likely due to more extensive posterior débridement. Greater pain relief was achieved with the arthroscopic procedure, likely due to decreased scar formation.
Therefore, arthroscopic technique may be considered in patients with moderate pain and arthritic changes in the anterior compartment of the elbow, whereas open ulnohumeral arthroplasty is preferred when advanced arthritic changes are present in both compartments of the joint.
There have been no reports of postoperative instability.
COMPLICATIONS
The complication rate for this procedure is very low, in contrast to most reconstructive procedures of the elbow.1,3,4,9,10,14,15,16,17,18,19
Symptom recurrence rate is less than 10%.
Iatrogenic ulnar nerve palsy can occur intraoperatively with the arthroscopic technique as well as with overzealous use of retractors in open technique. Additionally, postoperative ulnar nerve symptomatology has been reported as a result of significant increase of elbow flexion in patients with severe preoperative
elbow stiffness.1,7 We recommend prophylactic release of the ulnar nerve in elbows with less than 100 degrees of preoperative flexion.21
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FIG 3 • AP and lateral radiographs after ulnohumeral arthroplasty has been performed. The foraminectomy in the distal humerus can be easily seen. There are no osteophytes of the olecranon and coronoid process and the patient has gained a much better arc of motion without pain.
Heterotopic ossification with limited elbow motion has been described in one report after open
ulnohumeral arthroplasty with a triceps splitting approach.2 However, development of heterotopic ossification without limitation in motion has also been reported in some cases after arthroscopic
technique.16
Improper placement of the foraminectomy may result in a column fracture. Also, a fracture may occur if maximum loading is applied immediately postoperatively due to weakening of the columns of the distal
humerus.5
REFERENCES
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Antuna SA, Morrey BF, Adams RA, et al. Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: long-term outcome and complication. J Bone Joint Surg Am 2002;84-A(12):2168-2173.
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Chandrasenan J, Dias R, Lunn PG. Heterotopic ossification after the Outerbridge-Kashiwagi procedure in the elbow. J Shoulder Elbow Surg 2008;17:e15-e17.
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Cohen AP, Redden JF, Stanley D. Treatment of osteoarthritis of the elbow: a comparison of open and arthroscopic debridement. Arthroscopy 2000;16:701-706.
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Degreef I, De Smet L. The arthroscopic ulnohumeral arthroplasty: from mini-open to arthroscopic surgery. Minim Invasive Surg 2011;(2011):798084.
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Degreef I, Van Audekercke R, Boogmans T, et al. A biomechanical study on fracture risks in ulnohumeral
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Forster MC, Clark DI, Lunn PG. Elbow osteoarthritis: prognostic indicators in ulnohumeral debridement— the Outerbridge-Kashiwagi procedure. J Shoulder Elbow Surg 2001;10:557-560.
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Jeon IH, Lee SM, Kim PT. Acute ulnar nerve palsy after Outerbridge-Kashiwagi procedure. J Hand Surg Eur Vol 2007;32:596.
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Kashiwagi D. Outerbridge-Kashiwagi arthroplasty for osteoarthritis of the elbow. In: Kashiwagi D, ed. Elbow Joint: Proceedings of the International Congress, Kobe, Japan. Amsterdam: Elsevier Science Publishers, 1986:177-188.
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Minami M, Kato S, Kashiwagi D. Outerbridge-Kashiwagi's method for arthroplasty of osteoarthritis of the elbow: 44 elbows followed for 8-16 years. J Orthop Sci 1996;1:11-15.
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Morrey BF. Primary degenerative arthritis of the elbow. Treatment by ulnohumeral arthroplasty. J Bone Joint Surg Br 1992;74(3):409-413.
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Morrey BF. Primary degenerative arthritis of the elbow: ulnohumeral arthroplasty. In: Morrey BF, ed. The Elbow and Its Disorders. Philadelphia: WB Saunders, 2000:799-808.
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Morrey BF. Ulnohumeral arthroplasty. In: Morrey BF, ed. Master Techniques in Orthopaedic Surgery: The Elbow. New York: Raven Press Ltd, 1994:277-289.
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O'Driscoll SW. Elbow arthritis: treatment options. J Am Acad Orthop Surg 1993;1:106-116.
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Redden JF, Stanley D. Arthroscopic fenestration of the olecranon fossa in the treatment of osteoarthritis of the elbow. Arthroscopy 1993;9:14-16.
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Sarris I, Riano FA, Goebel F, et al. Ulnohumeral arthroplasty: results in primary degenerative arthritis of the elbow. Clin Orthop Relat Res 2004;(420):190-193.
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Savoie FH III, Nunley PD, Field LD. Arthroscopic management of the arthritic elbow: indications, technique, and results. J Shoulder Elbow Surg 1999;8:214-229.
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Tsuge K, Mizuseki T. Debridement arthroplasty for advanced primary osteoarthritis of the elbow. J Bone Joint Surg Br 1994;76(4): 641-646.
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Tsuge K, Murakami T, Yasunaga Y, et al. Arthroplasty of the elbow. Twenty years' experience of a new approach. J Bone Joint Surg Br 1987;69:116-120.
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Ugurlu M, Senkoylu A, Ozsoy H, et al. Outcome of ulnohumeral arthroplasty in osteoarthritis of the elbow. Acta Orthop Belg 2009;75:606-610.
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Vingerhoeds B, Degreef I, De Smet L. Debridement arthroplasty for osteoarthritis of the elbow
(Outerbridge-Kashiwagi procedure). Acta Orthop Belg 2004;70:306-310.
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Williams BG, Sotereanos DG, Baratz ME, et al. The contracted elbow: is ulnar nerve release necessary? J Shoulder Elbow Surg 2012;21:1632-1636.