Shoulder and Elbow cases posttraumatic elbow arthritis

A 20-year-old male presents to the office with right elbow pain. He states he fell 5 years ago and was told he broke his elbow but was treated without surgery. He has since developed worsening pain in his elbow with pain present throughout his entire arc of motion. The pain is more severe in the morning and at night, and he reports frequent swelling of his elbow. He is active and has not yet had any formal treatment. His x-rays can be seen in Figures 2–104 and 2–105.

 

 

 

Figure 2–104

 

 

Figure 2–105

 

Initial management includes which of the following?

1. Arthroscopic debridement

2. Corticosteroid injection and physical therapy

3. Hinged elbow brace

4. Total elbow arthroplasty

5. Radial head resection

 

Discussion

The correct answer is (B). Young active patients with post-traumatic arthritis are challenging, and achieving an elbow equal to that of the normal contralateral arm is unlikely. Treatment should consist of conservative measures until the level of pain or patient loss of function requires more aggressive treatment. Arthroscopic debridement works better for patients with pain at the extremes of motion rather than throughout the entire arc. Total elbow is a poor option at this point given the age and activity level of the patient.

For a young patient with elbow arthritis and pain only at extremes of motion, what would be the most appropriate surgical intervention?

1. Radial head replacement

2. Radial head resection

3. Arthroscopic osteocapsular debridement

4. Distal humerus osteotomy

5. Fascial interpositional arthroplasty

 

Discussion

The correct answer is (C). Pain at terminal motion is a symptom that is present in the early stages of arthritis. It is often due to periarticular osteophytes and capsular contracture with relative sparing of the articular surface. Radial head replacement and partial ulnohumeral arthroplasty is a viable option with arthritis isolated to one compartment. Fascial interposition arthroplasty is more appropriate for a patient with end stage arthritis with destruction of the majority of the articular bearing surface.

For a young patient with elbow arthritis and pain throughout the arc of motion, which of the following would be the best surgical option?

1. Arthroscopic debridement

2. Microfracture

3. Open osteocapsular debridement

4. Fascial interposition arthroplasty

5. Total elbow arthroplasty

 

Discussion

The correct answer is (D). Fascial interposition arthroplasty (Fig. 2–106) has shown to produce reliable pain relief in young patients in which a total elbow would not be appropriate. It typically involves resurfacing the bearing surface with either autograft or allograft. Although most patients see improvement with this procedure, it is still seen as a salvage procedure with one of its main benefits being that it does not compromise subsequent procedures. Figure 2–107 shows a decision-making algorithm for treatment based on the current stage of elbow osteoarthritis.

 

 

 

Figure 2–106 Reproduced with permission from Cheung EV, et al. Primary OA of the Elbow: Current Treatment Options. JAAOS 2008;16(2):77–87.

 

 

 

 

Figure 2–107 Reproduced with permission from Cheung EV, et al. Primary OA of the Elbow: Current Treatment Options. JAAOS 2008;16(2):77–87.

 

Objectives: Did you learn...?

 

Understand the primary goals of treatment for a young patient with posttraumatic elbow arthritis?

 

Be able to differentiate patients that have pain at terminal motion versus pain throughout the arc of motion?

 

Understand indications and outcomes of the surgical options?