ARTHRITIS - pediagenosis
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Monday, April 19, 2021


Primary osteoarthritis of the elbow is uncommon, unlike in the hip and knee; and the need for joint replacement in the elbow is much less common than the hip, knee, and shoulder. Elbow arthritis often develops in patients who repetitively load the joint, such as heavy laborers or athletes. It more commonly occurs in males and in the dominant extremity. Symptoms typically include pain and loss of motion. Pain typically occurs at the end ranges of motion, particularly terminal extension, from impingement due to osteophytes. Pain through the midrange of elbow motion is much less common but may develop if the articular cartilage loss is severe enough.
Other common causes of elbow arthritis include inflammatory conditions, most commonly rheumatoid arthritis, and trauma, most commonly after an intra-articular fracture. The elbow is a common site of involvement in rheumatoid arthritis, but the pharmacologic advances in treatment of this disease have made the progression of arthritis and symptoms much less severe. Although advances in implants have helped in the surgical treatment of intra-articular elbow fractures, post-traumatic arthritis can still occur.
Nonoperative management of elbow arthritis is the initial treatment and includes activity modification, range-of-motion exercises, use of braces and other support devices, intra-articular cortisone injections, and administration of nonsteroidal anti-inflammatory drugs or disease-modifying antirheumatic drugs.

Initial surgical treatments for elbow arthritis include open or arthroscopic debridement procedures (see Plate 2-33). These surgeries are done to improve pain and range of motion, and may include removal of loose bodies, osteophyte resection, capsular release or excision, and synovectomy. Recovery time can be shorter after an arthroscopic debridement, but there is a potential risk of neurovascular injury with this technique.
This risk is particularly increased in patients who have undergone prior surgery in the elbow, owing to the distortion of normal anatomy. In osteoarthritis, osteophytes commonly form at the tip of the olecranon and the olecranon fossa and at the tip of the coronoid and the coronoid fossa. These bone spurs can cause impingement-type pain at the end ranges of motion, and their removal can help relieve such symptoms.
Synovitis is a common source of pain and limited motion in a patient with rheumatoid arthritis; there fore, surgical synovectomy can be beneficial and may also prevent further destruction of cartilage and bone. Finally, ulnar nerve symptoms may develop in an arthritic elbow with significant loss of range of motion, and thus ulnar nerve decompression or transposition is recommended in combination with the debridement procedure in such situations.
Although debridement procedures can provide significant symptom relief, they may not be as beneficial in patients with more advanced arthritis and their effect may wear off over time as the arthritis progresses. In these instances, surgery is aimed at reconstruction of the diseased elbow joint. Most commonly, this is in the form of a total elbow replacement, but other techniques have occasionally been employed, including interpositional arthroplasty, resection arthroplasty, and elbow arthrodesis. Interpositional arthroplasty may be an option in younger patients with severe arthritis, who may be too active for consideration of a total elbow replacement. The procedure involves covering the diseased joint surfaces with a biologic material (e.g., autogenous fascia lata, dermal allograft) to improve pain and range of motion (see Plate 2-34). Resection arthroplasty is not commonly used today as a primary treatment for arthritis because of the resultant instability and dysfunction at the elbow after this procedure, although bony ankylosis can occur. It is primarily considered as a salvage procedure in cases of failed prior surgery and intractable infection. Elbow arthrodesis is also rarely used currently, because fusion in a single position can be difficult for reasonable upper extremity function. It can be considered a salvage procedure in cases of infection and may rarely be considered an option in a young heavy laborer who may place too high a demand on an elbow replacement.

Severe, disabling arthritis is best treated with total elbow arthroplasty. Total joint replacement restores joint motion and relieves pain by replacing the diseased articular surfaces with a plastic and metal prosthesis. The typical implant is an ulnohumeral arthroplasty, with a stemmed, metallic humeral implant and a stemmed, metallic ulnar implant that articulate through a polyethylene-bearing surface (see Plate 2-34). Both linked and unlinked prosthetic designs are available. Linked implants directly connect the humeral and ulnar components through the bearing surface and are indicated in patients with excessive bone destruction and/ or ligamentous destruction or instability. The hinge mechanism can be classified as constrained or semiconstrained on the basis of the absence or presence of side-to-side laxity in the implant. Modern linked designs have a semiconstrained articulation that allows some side-to-side laxity, in order to decrease stress across the implant and lower the rate of component loosening (see Plate 2-35). Unlinked prostheses have no direct connection between the humeral and ulnar components and, therefore, require the presence of adequate bone stock and intact or reconstructed collateral ligaments (see Plate 2-35). If functional collateral ligaments are not present, implant failure can occur due to instability.
The most common complication of total elbow arthroplasty and the one that causes the most concern over time is implant loosening and resultant instability. Implant survival rates vary depending on the etiology of the underlying arthritis, with survival rates as high as 94% at 15 years in rheumatoid arthritis patients but as low as 70% at 15 years in the post-traumatic population. This discrepancy is due in part to differences in age and activity level, with patients undergoing total elbow replacement for post-traumatic arthritis usually of a much younger age and/or higher activity level than rheumatoid arthritis patients.
Arthritic changes at the radiocapitellar joint may also need to be treated with joint replacement, either in isolation or in combination with total elbow arthroplasty. This is most commonly addressed with radial head resection or replacement (see Plate 2-25). Whereas resection of the radial head alone can provide pain relief, over time it may lead to proximal displacement of the radial shaft if the interosseous membrane and distal radioulnar joint are or become deficient.

Proximal radial migration can cause pain and dysfunction, particularly with pronation-supination movements. These complications can be avoided by using a radial head replacement. Traditional implants were made of silicone, but this material has been replaced by metallic prostheses because of the high complication rate noted with silicone, particularly the generation of a signi cant inflammatory response from particulate debris.

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