Posttraumatic Elbow Osteoarthritis

Introduction

Trauma to the elbow resulting in damage to the articular cartilage or residual surface in congruencies can alter the load distribution across bearing surfaces and place the joint at risk for development of degenerative changes and early-onset arthritis. Posttraumatic articular injuries may be isolated to specific areas of the elbow, such as the radiocapitellar joint or can encompass the entire joint, resulting in profound functional limitations and pain. The treatment of posttraumatic elbow arthritis can be quite challenging as the majority of these patients are young and active. Total elbow arthroplasty (TEA), which is an acceptable first-line treatment in the elderly or low-demand patient population, should be viewed only as a salvage option in the young, active patient population due to increased demands placed across the implant throughout the patient's lifetime. Therefore, the goals of treatment in this population are directed at providing a minimally painful and functional elbow articulation, while maintaining future salvage options.

Patient Evaluation: History and Physical Examination

An accurate characterization of normal and pathologic elbow structures is important to guide treatment planning, in order to determine which clinical feature is most limiting for each patient so the best treatment option may be offered. The patient's history of the initial elbow injury should include mechanism of injury, types of fractures or instability, subsequent treatment, and any history of infection. Evaluating initial injury films as well as previous operative reports is especially useful to understand degree of displacement, comminution, and articular involvement, as well as to determine prior surgical exposures, nerve transposition, type of hardware, and previous complications.

Physical examination of the elbow should include evaluation for deformity, swelling, drainage, crepitance, and previous surgical incisions. An accurate assessment of the arc of motion, including level and location of pain, compared to the contralateral elbow is critical to assess functionality of the limb. The surrounding myotendinous structural integrity and strength, along with collateral ligament stability, should be assessed. Finally, a complete vascular and neurologic evaluation should be conducted including focused assessment of ulnar nerve sensory function and motor function, along with any existing irritability or subluxation.

The subsequent treatment plan should focus on the primary patient complaint as it relates to pain, stiffness, or instability. If pain is the primary complaint, it should be determined if pain occurs predominantly at terminal motion (impingement), throughout the entire arc of motion, and/or at rest. Impingement-type pain, secondary to osteophyte formation or capsular contracture, can limit the arc of motion. Pain occurring throughout the entire arc of motion, in general, indicates a joint with a damaged bearing surface and advanced degenerative changes. This can be associated with night pain, effusions, and progressive stiffness. Pain at rest is approached with caution regardless of radiographic changes as this complaint may represent nonarticular pain such as infection, cervical spine radicular pain, soft tissue disease, or complex regional pain syndrome.

Imaging and Other Complementary Tests

Conventional radiographs consisting of at least two orthogonal views of the elbow (anteroposterior and lateral) are the standard initial evaluation for posttraumatic osseous deformity and are useful to evaluate the extent of degenerative disease and detect even subtle degenerative changes including osteophyte formation, loose bodies, and joint space narrowing.

Computed tomography (CT) can improve accuracy and has a higher interobserver agreement when compared to conventional radiography for the detection of osteophytes and loose bodies. 3D reconstruction CT technology has further been shown to improve visualization of osteophyte distribution as well as to assess complex deformity patterns to aid in planning surgical debridement. CT-arthrogram or MRI can be used to evaluate cartilage injuries and soft tissue pathology ; however, the ability of either technology to screen for suspected cartilage lesions still remains limited. Theodoropoulous et al. reported on the accuracy rate of MRI for arthroscopically proven cartilage lesions, finding an accuracy rate of only 45% for the radius, 65% for the capitellum, 20% for the ulna, and 30% for the trochlea with no difference in accuracy with MRA. At this time, the clinical utility of MRI in the posttraumatic osteoarthritic elbow remains unknown, and these studies are not routinely required. As a result of these limitations, there may be a role for diagnostic arthroscopy for suspected cartilage lesions.

Ruling out infection is paramount prior to planned surgical interventions. In the setting of possible septic arthritis, an elbow aspiration for cell count with differential and cultures is compulsory. In patients with previous open injuries, past history of infection, associated nonunion, or a worrisome clinical presentation, preoperative testing for potential infection is required. Perioperative testing should include peripheral blood cell count, sedimentation rate, and C-reactive protein, as well as intraoperative bone and soft tissue cultures and pathology, and the consideration for staging definitive procedures. Finally, electromyographic (EMG) evaluation should be obtained in patients with peripheral neuropathies to establish a baseline for assessing prognosis of nerve function recovery.

Treatment

The mainstay of early treatment for patients with posttraumatic arthritis is directed at maintaining joint mobility and reducing activities that place stress across the elbow, such as weight bearing and repetitive motions. Nonoperative measures may ultimately be definitive for mild arthrosis and can be used as a temporizing measure prior to any surgical intervention for advanced arthritis. Nonsteroidal antiinflammatory medications and selective intraarticular corticosteroid injections can be utilized initially to control pain and facilitate daily use of the arthritic elbow ( Fig. 75.1 ).

For patients who fail nonoperative management, treatment is geared at restoring elbow function and reducing pain ( Fig. 75.2 ). Typically, patients with stiffness and pain at terminal motion (impingement) benefit from osteocapsular joint debridement and removal of osteophytes. When patients complain of pain throughout the entire arc of motion and have advanced degenerative disease on imaging, consideration for joint resurfacing may be appropriate. Patients who have failed all other treatment measures may be candidates for total joint replacement, as long as restrictions associated with implants (10 pounds for any single lift and under 2–5 pounds for repetitive lifting) and likelihood of future revision in younger patients are accepted. Ultimately, treatment is aimed at restoration of a functional joint with preservation of future surgical salvage options.