Shoulder and Elbow cases osteoarthritis of the elbow
A 53-year-old, left-hand-dominant male presents to your office for evaluation regarding his elbow pain. He states that for the past 5 years he has had pain in his left elbow. It seems to be worsening over the past 6 months. He states he works as a mechanic and the pain is limiting the amount of time he can spend working. He takes anti-inflammatories with some relief. His images are shown (Figs. 2–97 and 2–98).
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Figure 2–97
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Figure 2–98
Which of the following symptoms is common in the early stages of osteoarthritis (OA)?
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Pain when carrying heavy objects with the elbow in extension
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Pain at mid-arc range of motion
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Motion loss greater than 30 degrees
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Ulnar neuritis
Discussion
The correct answer is (A). Pain when carrying heavy objects with the elbow in extension is a classic presentation for patients with early disease. They also have
motion loss less than 15 degrees and respond well to conservative treatments. Patients with intermediate disease have moderate pain at the ends of motion, often have loss of extension >30 degrees and have ulnar nerve symptoms. Patients with end-stage OA have pain in the mid-arc of motion, have failed conservative treatment and have motion loss greater than 30 degrees.
When is simultaneous osteocapsular debridement and ulnar nerve decompression warranted?
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Ulnar neuritis and flexion less than 100
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Patients with motion loss less than 15 degrees
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All patients who get surgical treatment for elbow OA should get their ulnar nerve decompressed
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It is never appropriate to decompress the ulnar nerve simultaneously as it makes future surgery more risky
Discussion
The correct answer is (A). The ulnar nerve is commonly inflamed in OA of the elbow. The increase in motion seen postoperatively is thought to increase the traction placed on the nerve, and has been shown to be a limiting factor in patients final outcome. It is important to clearly document if the nerve was left in situ or was transposed to prevent injury during subsequent surgery.
Which of the following is predictive of postoperative motion following arthroscopic osteocapsular debridement?
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Preoperative motion
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Intraoperative motion
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Motion seen at 2 weeks postoperative
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Amount of preoperative pain based on the visual analog scale (VAS)
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Degree of joint space narrowing
Discussion
The correct answer is (B). It has been shown that the amount of motion achieved after completion of the soft tissue and bony release correlates the most with final outcome.
What is the most common complication of total elbow arthroplasty in a younger population?
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Infection
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Triceps avulsion
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Aseptic/mechanical loosening
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PIN neuropraxia
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Ulnar nerve neuropraxia
Discussion
The correct answer is (C). Aseptic or mechanical loosening is the most common cause of failure in the younger, more active population. The estimated incidence of implant loosening is between 7% and 15%. Although the newer, semi-constrained prosthesis has significantly lower rates of loosening than the fully constrained implant, mechanical failure is still of primary concern. Infection occurs between 5% and 8% of the time, and triceps insufficiency is from 3% to 8%.
What restrictions would the patient have to adhere to if he wished to proceed with total elbow arthroplasty?
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Cannot extend beyond 30 degrees
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10 lb life-long weight limit
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Must take daily prophylactic antibiotics for 10 years postoperatively
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Would be unable to pronate and supinate
Discussion
The correct answer is (B). Patients are advised to lift no more than 10 lb for a single lift and no more than 2 to 5 lb for repetitive lifting for the duration of their life. Despite this precaution, there is still a high rate of revision for aseptic loosening.
Objectives: Did you learn...?
Identify etiology and natural history of osteoarthritis of the elbow? Identify indications for selecting different treatment options?
Recognize common complications seen with total elbow replacement?