Primary osteoarthritis of the elbow: Lack of radiographic evidence for morphologic predisposition, results of operative debridement at intermediate follow-up, and basis for a new radiographic classification system

doi:10.1016/j.jse.2007.03.014

Journal of Shoulder and Elbow Surgery

Volume 17, Issue 1, January–February 2008, Pages 97-105

https://doi.org/10.1016/j.jse.2007.03.014 Get rights and content

This study evaluated whether or not a morphologic predisposition exists to the development of primary osteoarthritis and establishes a classification tool to predict outcome in surgical treatment of elbow osteoarthritis. Detailed radiographic morphologic analysis of the ulnotrochlear and radio-capitellar joints in 90 normal and 24 osteoarthritic elbows showed few differences. Based upon commonly demonstrated radiographic features of degenerative changes, joint space narrowing, and marginal osteophytes, a classification system for rating the severity of primary osteoarthritis of the elbow was developed and applied retrospectively classified the preoperative radiographs of 18 patients (21 elbows) who had undergone elbow debridement and capsular release through a lateral collateral ligament preserving approach. Clinical and radiographic outcomes were assessed at an average 65 months postoperative. Total elbow motion and Mayo elbow performance scores were best in those who had been classified as class I preoperatively and worst in those in class III. This newly developed radiographic classification system is a useful tool in predicting surgical outcome following debridement of primary elbow osteoarthritis.

Section snippets

Evaluation of radiographic elbow morphology

The AP and lateral radiographs of 90 normal elbow joints were evaluated. Multiple measurements were developed for the purpose of defining radiocapitellar and ulnotrochlear morphology on both the AP and lateral elbow projection radiographs. Ten different measurements of the trochlea and radiocapitellar joints were utilized. Trochlear morphology was defined by 5 length measurements and a lateral and medial facet angle on the AP projection (Figure 1). Lateral radiographs were utilized to assess

Radiographic measurements of the normal and OA elbow

Comparing radiographic measurements from the elbow radiographs with and without OA, 2 variables were found to be statistically significant. There was a significant difference in the lateral facet angle between normal elbows and those with primary OA (27.2° compared to 31.8°, respectively, P < 0.0002). There was also a significant difference between the 2 groups for the radial neck midaxial line capitellar center distance. Primary OA and normal elbows had a mean distance of 1.8 and –0.5 mm,

Discussion

The etiology of primary OA of the elbow remains unclear. Mechanical factors associated with certain occupations as a cause has been well documented12, 20, 21, 22. Rostock et al investigated 744 miners using pneumatic tools and found that 32% had elbow OA compared with 2% in the community. Others have reported primary OA of the elbow in which no occupational related hazards could be found.⁵ Anthropologic studies have demonstrated differences in incidences of elbow OA among races.¹⁸ The cause of

Conclusions

A method for anatomically evaluating distal humerus morpholgy is presented, which may be used as a standard for other investigators to further evaluate whether anatomic factors play a role in the development of primary osteoarthritis. In this study, no significant radiographic morphologic differences were noted among patients with normal elbows and those with primary osteoarthritis. The projected radial axis to capitellar center distance is useful to quantify radial head subluxation.

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Radiologically severe osteoarthritis is related to worse clinical outcomes after arthroscopic osteocapsular arthroplasty in primary elbow osteoarthritis at medium-term follow-up: a retrospective cohort study
2023, Journal of Shoulder and Elbow Surgery
This study aimed to compare the clinical outcomes after arthroscopic osteocapsular arthroplasty (OCA) at medium-term follow-up according to the radiologic severity of primary elbow osteoarthritis (OA) and assess serial changes in clinical outcomes in each group.
Patients treated from January 2010 to April 2019 with arthroscopic OCA for primary elbow OA with a minimum of 3 years’ follow-up were retrospectively assessed regarding range of motion (ROM), visual analog scale (VAS) pain score, and Mayo Elbow Performance Score (MEPS) preoperatively, at short-term follow-up (3-12 months postoperatively), and at medium-term follow-up (≥3 years after surgery). Preoperative computed tomography was performed to evaluate the radiologic severity of OA using the Kwak classification. Clinical outcomes were compared according to the radiologic severity of OA by their absolute values and the number of patients achieving the patient acceptable symptomatic state (PASS). Serial changes in the clinical outcomes in each subgroup were also assessed.
Of the 43 patients, 14, 18, and 11 were classified as the stage I, II, and III groups, respectively; the mean follow-up duration was 71.3 ± 28.9 months, and the mean age was 56.5 ± 7.2 years. At medium-term follow-up, the stage I group had a better ROM arc (stage I, 114° ± 14°; stage II, 100° ± 23°; and stage III, 97° ± 20°; P = .067) and VAS pain score (stage I, 0.9 ± 1.3; stage II, 1.8 ± 2.1; and stage III, 2.4 ± 2.1; P = .168) than the stage II and III groups without reaching statistical significance, whereas the stage I group had a significantly better MEPS (stage I, 93.2 ± 7.5; stage II, 84.7 ± 11.9; and stage III, 78.6 ± 15.2; P = .017) than the stage III group. The percentages of patients achieving the PASS for the ROM arc (P = .684) and VAS pain score (P = .398) were comparable between the 3 groups; however, the percentage achieving the PASS for the MEPS was significantly higher in the stage I group than in the stage III group (100.0% vs. 54.5%, P = .016). During serial assessment, all clinical outcomes tended to improve at the short-term follow-up. Compared with the short-term period, the ROM arc tended to decrease at the medium-term follow-up whereas the VAS pain score and MEPS overall did not show significant changes.
After arthroscopic OCA, the stage I group showed an overall better ROM arc and pain score than the stage II and III groups at medium-term follow-up, whereas the stage I group showed a significantly better MEPS and higher percentage of patients achieving the PASS for the MEPS than the stage III group.
Elbow Arthritis
2023, Journal of Hand Surgery
Elbow arthritis is an uncommon condition that can cause debilitating pain, stiffness, or instability. The most common etiologies include rheumatoid arthritis, posttraumatic arthritis, and primary osteoarthritis. Treatment begins with nonsurgical modalities, including activity modification, anti-inflammatories, hand therapy, and corticosteroids. Operative intervention may be considered once nonsurgical management has failed. Surgical treatment depends on the underlying etiology, chief complaint, patient age, and functional demand. Advances in technology, especially arthroscopic techniques, have expanded the treatment options available to surgeons. The goals of treatment include pain relief and restoration of functional range of motion. The purpose of this article is to review the pertinent soft tissue and osseous anatomy, discuss the etiologies, review the principles of diagnosis and evaluation, and finally, study the treatment options for elbow arthritis.
Long-term survivorship of open débridement and débridement arthroplasty for elbow arthritis: a retrospective chart review
2022, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
We graded the severity of elbow arthritis based on preoperative radiographs. Historically, the Hastings-Rettig classification has been used for primary osteoarthritis; this classification is based on the presence of subluxation and involvement of the radiocapitellar joint.27 In contrast, the Broberg and Morrey system has typically been used in cases of post-traumatic arthritis according to osteophyte formation and joint space narrowing.5
Open débridement and Outerbridge-Kashiwagi (OK) débridement arthroplasty (OK procedure) are common surgical treatments for elbow arthritis, but little is known about their long-term survivorship. The purpose of this study was to determine whether survivorship until conversion to total elbow replacement and revision surgery was better for the OK procedure compared with open débridement.
We performed a retrospective chart review of patients who underwent open elbow surgical débridement (open débridement or OK procedure) between 2000 and 2015. Patients received a diagnosis of primary elbow osteoarthritis, post-traumatic arthritis, or inflammatory arthritis. A total of 320 patients underwent surgery including open débridement (n = 142) or the OK procedure (n = 178), and of these patients, 33 required secondary revision surgery (open débridement, n = 14; OK procedure, n = 19). The average time since surgery was 11.5 years (range, 5.5-21.5 years). Survivorship was analyzed with Kaplan-Meier curves and the log rank test. A Cox proportional hazards model was used to estimate the effect of the type of procedure, index diagnosis, age, and sex on survivorship.
Kaplan-Meier survival curves showed survivorship rates until total elbow arthroplasty of 100.0% at 1 year, 99.3% at 5 years, and 98.5% at 10 years for open débridement and 100.0% at 1 year, 98.8% at 5 years, and 98.0% at 10 years for the OK procedure (P = .87). There was no difference in survivorship between procedures, even after adjustment for significant covariates. The rates of revision for open débridement and the OK procedure were similar, at 11.3% and 11.5%, respectively, after 10 years. Higher rates of revision surgery were observed in patients who underwent open débridement (hazard ratio, 4.84; 95% confidence interval, 1.29-18.17; P = .019) compared with those who underwent the OK procedure after adjustment for covariates. We performed a stratified analysis with radiographic severity as an effect modifier and showed that patients with grade 3 arthritis fared better after the OK procedure compared with open débridement in terms of survivorship until revision surgery (P = .05). However, such a difference was not found for grade 1 or grade 2 arthritis.
We showed that both open elbow débridement and the OK procedure had excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post-traumatic cases that could help delay the need for total elbow arthroplasty. Patients with more severe radiographic arthritis, specifically grade 3 arthritis, were less likely to require revision surgery if treated initially with the OK procedure compared with open débridement.
Silicone radial head prostheses: the clinical course and treatment of failure—a case series
2022, Journal of Shoulder and Elbow Surgery
Silicone radial head prostheses (SRHP) have a reputation of acceptable initial function but failure in the medium to long term as a result of the disintegration of the silicone material. Damaged SRHP can result in a silicone-induced synovitis and destruction of the joint. Early removal of damaged SRHP may prevent joint destruction. Literature is scarce; there are no studies describing early symptoms associated with clinical failure of SRHP and very few studies on appropriate treatment of destructed SRHP. The aim of this study was to describe the clinical course of failing SRHP and to provide practical guidance for treatment.
Fifteen consecutive cases of failed SRHP, operated between 2005 and 2020, were retrospectively reviewed, using patient logs, radiographic results, and a questionnaire. Relevant data concerning pre- and postoperative complaints, function, and surgical details were gathered. Using the questionnaire, retrospective and current patient reported outcomes including Single Assessment Numeric Evaluation (SANE) scores, pain, instability, and range of motion were analyzed.
The average time between implantation of the SRHP until outpatient presentation was 16 years. The average recalled SANE score before start of complaints was 8.6 out of 10 points. In 4 patients, the onset of complaints was preceded by a trauma. Five patients had symptoms for more than a year, and 9 patients for several months. Progressive pain in the elbow and/or wrist and mechanical symptoms were early and prominent symptoms of failure. Clinical signs of synovitis were frequently present. The majority of patients had a slow but progressive onset of complaints over several months before presentation. Twelve of 15 cases of failed SRHP were surgically treated. Fragmentation of the implant, osteoarthritis, and synovitis were found in all surgically treated cases. Both surgical removal and synovectomy alone, and revision to a new radial head prosthesis resulted in good medium-term outcomes with a mean SANE score of 7.3 points at 8.4 years of follow-up. Postoperative extension lags and mild instability were frequently mentioned as a reason for reimplantation of a metallic radial head implant and removal of the radial head alone, respectively.
Both patients and physicians should be aware of early symptoms of a failing SRHP. Adequate recognition, radiographic evaluation, and early intervention may favor outcomes of failing SRHP. Surgical removal is easy to perform. In selected cases, revision of the radial head prosthesis may be considered. Both of these treatment strategies resulted in satisfying outcomes.
Primary Elbow Osteoarthritis: Evaluation and Management
2021, Journal of Clinical Orthopaedics and Trauma
Most patients with primary osteoarthritis of the elbow report a history of heavy lifting with the affected upper extremity
. Conservative treatment, including activity modifications, nonsteroidal anti-inflammatory drugs and the occasional intraarticular corticosteroid injection, may provide adequate pain relief in earlier stages
. When surgery is required, and despite the presence of cartilage wear, many patients with primary elbow osteoarthritis experience substantial pain improvement with joint preserving procedures
. The ulnar nerve needs to be carefully assessed and addressed at the time of surgery
. Although open debridement procedures are effective, arthroscopic osteocapsular arthroplasty has emerged as the surgical procedure of choice
. Total elbow arthroplasty is very successful in terms of pain relief and function, but it is reserved for patients with end-stage osteoarthritis who are relatively older and have failed joint preserving procedures.
Utility of a 3-dimensionally printed color-coded bone model to visualize impinging osteophytes for arthroscopic débridement arthroplasty in elbow osteoarthritis
2021, Journal of Shoulder and Elbow Surgery
The identification and precise removal of bony impingement lesions during arthroscopic débridement arthroplasty for elbow osteoarthritis require a high level of experience and surgical skill. We have developed a new technique to identify impinging osteophytes on a computer display by simulating elbow motion using the multiple positions of 3-dimensional (3D) elbow models created from computed tomography data. Moreover, an actual color-coded 3D model indicating the impinging osteophytes was created with a 3D printer and was used as an intraoperative reference tool. This study aimed to verify the efficacy of these new technologies in arthroscopic débridement for elbow osteoarthritis.
We retrospectively studied 16 patients treated with arthroscopic débridement for elbow osteoarthritis after a preoperative computer simulation. Patients who underwent surgery with only the preoperative simulation were assigned to group 1 (n = 8), whereas those on whom we operated using a color-coded 3D bone model created from the preoperative simulation were assigned to group 2 (n = 8). Elbow extension and flexion range of motion (ROM), the Mayo Elbow Performance Score (MEPS), and the severity of osteoarthritis were compared between the groups.
Although preoperative elbow flexion and MEPS values were not significantly different between the groups, preoperative extension was significantly more restricted in group 2 than in group 1 (P = .0131). Group 2 tended to include more severe cases according to the Hastings-Rettig classification (P = .0693). ROM and MEPS values were improved in all cases. No significant differences in postoperative ROM or MEPS values were observed between the groups. There were no significant differences in the improvement in ROM or MEPS values between the 2 groups.
The use of preoperative simulation and a color-coded bone model could help to achieve as good postoperative ROM and MEPS values for advanced elbow osteoarthritis as those for early and intermediate stages.

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: Presented at the 59^th meeting for the American Society for Surgery of the Hand, Chicago, Il, September 20, 2003.

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Original articlePrimary osteoarthritis of the elbow: Lack of radiographic evidence for morphologic predisposition, results of operative debridement at intermediate follow-up, and basis for a new radiographic classification system

Section snippets

Evaluation of radiographic elbow morphology

Radiographic measurements of the normal and OA elbow

Discussion

Conclusions

J Shoulder Elbow Surg

Arthroscopy

J Shoulder Elbow Surg

J Arthroplasty

Orthop Clin North Am

J Shoulder Elbow Surg

J Hand Surg [Am]

Ulnohumeral arthroplasty for degenerative arthritis of the elbow

J Bone Joint Surg Am

Post-traumatic contracture of the elbow operative release using a lateral collateral sparing approach

J Bone Joint Surg Br