Arthroscopy for Arthritis of the Elbow

Introduction

Degenerative arthritis of the elbow seems to be growing more common and may be a cause of substantial disability. Although initial treatment is usually nonoperative, the arthritis often progresses and has been historically managed by open measures. Since the initial report of arthroscopic management of the degenerative elbow by Savoie et al., arthroscopy has become a more common treatment modality, with results comparable to or better than similar open procedures. This chapter will summarize the current application of arthroscopy for the arthritic elbow.

History and Physical Examination

The etiology of primary osteoarthritis of the elbow is usually thought to be genetic or posttraumatic, but it may occur in manual laborers, athletes, or others whose activities produce excessive stress on the joint.

Symptoms of arthritis include loss of motion, mechanical catching and locking, and pain. Pain is usually present at the terminal arc of motion but may occur during any part of movement. Inspection may show deformity and muscle atrophy. Physical examination reveals crepitation, abnormal movement patterns, and a decreased arc of motion. Tenderness may be present over the arthritic deformities, over the radiocapitellar articulation, and on the epicondyles. Swelling is usually present and may be observed primarily in the lateral gutter. The normal plica on the posterior lateral elbow will usually be enlarged and tender.

There may also be spurs present on the medial side, and in some cases the medial spurs may put pressure on the ulnar nerve. In posttraumatic cases, the nerve may also be tethered by adhesions. In each of these cases, there may be a Tinel's sign near the cubital tunnel. The ulnar nerve should always be evaluated in the arthritic elbow for these problems in order to decrease the incidence of postoperative complications related to the nerve during restoration of motion. Electrical studies may also be useful to document irritation of the ulnar nerve if the clinical exam suggests entrapment or tethering.

Diagnostic Imaging

Plain film radiographs should be obtained, and they typically demonstrate hypertrophic bony spurs and loose bodies ( Figs. 21.1 and 21.2 ). The bone is generally sclerotic rather than osteopenic (as observed in rheumatoid arthritis). Computed tomography (CT) scans may be useful, particularly with three-dimensional (3D) reconstructions, to map out areas of interest that will require recontouring if this is not readily apparent on the plain radiographs. Using the 3D CT as a preoperative planning tool allows the surgeon to gain an increased appreciation for the osteophytic areas that require attention, to improve the range of motion, and to achieve a satisfactory result.

Indications for Surgery

Nonoperative treatment options, such as nonsteroidal antiinflammatory medications, corticosteroid injections, and activity modifications, should be exhausted prior to considering surgery. Pain, functional impairment, and a failure of nonoperative treatment are the main indications for surgery. In the arthritic elbow, this indication is usually represented by pain at the end arc of motion, mechanical symptoms, or joint contracture that limits activity. As with all arthritic problems, the primary indication for surgery is the decision of the patient, not the physician.

Excision of the radial head during the surgery will depend on the preoperative evaluation. In posttraumatic arthritis, where the initial injury was on the radial column, it is often necessary to excise the radial head. Limitations of pronation and supination also represent an indication for radial head excision.

The main potential problem with arthroscopic debridement surgery for arthritis involves risks to the ulnar nerve. In the arthritic elbow, medial spurs often produce pressure on the nerve from within the joint. Additionally, a subluxating ulnar nerve or a prior subcutaneous ulnar nerve transposition are not necessarily contraindications to arthroscopy of the elbow; however, an intermuscular or submuscular transposition is often considered a relative contraindication unless the precise course of the nerve can be ascertained by visual inspection, palpation, or ultrasonography. In any of these cases, the nerve should be carefully palpated and evaluated for location and mobility. If there is any question, a medial incision should be made and the nerve located, inspected, and then protected during the rest of the arthroscopic surgery.

Although the authors think that arthroscopic measures are the best treatment for the arthritic elbow, acceptable alternatives include open procedures, such as resection arthroplasty of the ulnohumeral joint, or open debridement, such as the Morrey ulnohumeral arthroplasty or the Outerbridge-Kashiwagi procedure. In addition, total elbow arthroplasty reliably relieves pain and motion but should be reserved for sedentary individuals with panarticular changes whose primary complaint is pain, not functional limitation. Arthrodesis of the elbow is reserved for cases in which there is no other option, and arthrodesis (joint fusion) is often difficult to achieve. At present, given all options, arthroscopic debridement with spur removal and fossa fenestration with or without radial head excision is the preferred treatment because of the ability to address all underlying pathologic processes and provide outcomes similar to, if not better than, open procedures.