The Ins and Outs of Primary Osteoarthritis of the Elbow
Learn about primary osteoarthritis of the elbow, a rare but debilitating disorder primarily affecting middle-aged men in heavy manual labor or athletics. Discover the definition, anatomy, pathogenesis, management, outcomes, and complications of this disorder in this informative blog post
Primary osteoarthritis of the elbow is a relatively rare but debilitating disorder. It primarily affects middle-aged men in heavy manual labor or athletics and can limit their ability to work and perform daily functions. In this blog post, we will discuss the definition, anatomy, pathogenesis, management, outcomes, and complications of primary osteoarthritis of the elbow.
Definition
Primary osteoarthritis of the elbow is a degenerative disorder that affects the elbow joint. It results in the breakdown and eventual loss of articular cartilage, leading to changes in joint morphology. This results in pain, stiffness, and limited range of motion. The disorder is relatively uncommon, accounting for only 1% to 2% of all cases of arthritis, and 2% of the general population.
Anatomy
The elbow joint consists of three separate articulations: the ulnohumeral, the radiocapitellar, and the proximal radioulnar joints. The normal range of elbow flexion-extension is 0 to 150 degrees, whereas normal forearm pronation-supination is 80 degrees. 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 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.
Pathogenesis
Symptomatic osteoarthritis of the elbow affects about 2% of the general population, primarily affecting males in middle age. The majority of patients experience symptoms in their dominant extremity due to overuse, such as through employment or sports. Pathologic changes that occur within the elbow joint include osteophyte formation on the olecranon, olecranon fossa, coronoid and coronoid fossa, as well as periarticular bone sclerosis and loose bodies.
Management
Nonoperative treatment may be helpful in early stages, but surgical intervention is indicated when symptoms do not improve with appropriate nonoperative management. Multiple operative techniques have been described for treatment of primary osteoarthritis of the elbow, including débridement arthroplasty, interposition arthroplasty, the Outerbridge-Kashiwagi procedure, arthroscopic débridement, and total elbow replacement. Ulnohumeral (Outerbridge-Kashiwagi) arthroplasty, first described in 1978, is based on a posterior approach to the elbow and has become the most popular form of treatment. Recent advancements allow the procedure to be performed with arthroscopic fenestration of the olecranon fossa, débridement, and removal of loose bodies.
Outcomes and Complications
A review of the literature shows satisfactory results in over 80% of patients with both open and arthroscopic techniques, with both procedures resulting in overall improvement of movement and pain relief. Complication rates are low, with a less than 10% recurrence rate of symptoms. Iatrogenic ulnar nerve palsy can occur intraoperatively, and postoperative ulnar nerve symptomatics have been reported. Heterotopic ossification and column fractures have been described as rare complications.
Surgical Technique
The following is a step-by-step surgical technique for Ulnohumeral (Outerbridge-Kashiwagi) arthroplasty:
- Exposure:
- After the skin incision, the subcutaneous tissue is reflected from the medial aspect of the triceps. The ulnar nerve is identified and decompressed at the cubital tunnel if the patient has ulnar nerve symptoms.
- 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.
- Osteophyte Removal and Olecranon Resection:
- The posterior osteophyte and the tip of the olecranon are removed by an oscillating saw to minimize impingement in extension. An osteotome is then used to complete the resection. A hole is drilled in the olecranon fossa to gain access to the anterior elbow compartment and the coronoid process.
- The foraminectomy in the distal humerus can be easily seen, and loose bodies and debris are removed from the anterior aspect of the elbow. The foraminectomy is enlarged in diameter to at least 1 cm using progressively larger drill bits.
- Once the foraminectomy of the olecranon fossa is complete, the anterior osteophyte from the coronoid process is removed by using a curved osteotome with maximum elbow flexion.
- Closure:
- All incisions are closed in standard fashion. The elbow is meticulously irrigated, and bone wax is used to cover the margins of the foramen. Gelfoam is inserted into the defect to fill the dead space. The elbow is carefully manipulated to maximize the total arc of motion.
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Conclusion
Primary osteoarthritis of the elbow is a rare but disabling disorder that is primarily treated through surgical intervention. Patients experiencing loss of motion or pain after nonoperative treatment should be carefully selected and thoroughly assessed with imaging studies. The ulnohumeral (Outerbridge-Kashiwagi) arthroplasty is the most popular and successful form of treatment, provided the surgeon maintains proper surgical technique and attention to patient selection and imaging studies.