Review Article Posttraumatic Elbow Arthritis in the Young ... › pdfs › ... · Treatment...

Posttraumatic Elbow Arthritis inthe Young Adult: Evaluation andManagement

Abstract

Degenerative joint disease following trauma to the elbow is difficultto manage in any patient. However, this condition becomessubstantially more challenging in the young, active population.Increased activity demands and limited functional capacity of totalelbow arthroplasty mean that joint arthroplasty should be regardedas a salvage procedure. The primary goal of treatment is to restorea pain-free or minimally painful functional joint while preservingfuture surgical options. This requires accurate assessment of theprimary patient complaint, be it terminal pain and stiffness or painalong the entire arc of motion. Patients who report stiffness andpain at terminal motion may benefit from arthroscopic or openosteocapsular débridement. Those with advanced degenerativechanges and pain throughout the entire arc of motion may requirejoint resurfacing with interposition arthroplasty, partial jointarthroplasty, or total joint arthroplasty.

Elbow trauma can result in a con-stellation of derangements, in-

cluding instability, malunion, andnonunion.1,2 In addition, articularcartilage damage or residual articu-lar surface incongruencies can alterload distribution across bearing sur-faces and lead to degenerativechanges and early-onset arthritis.2

Posttraumatic articular injury maybe isolated to specific areas of the el-bow (eg, radiocapitellar joint) ormay encompass the entire joint, re-sulting in profound functional limi-tations and pain (Figure 1).

Posttraumatic elbow arthritis inthe young patient is a relatively rarecondition that presents a challenge tothe practicing orthopaedic surgeon.Total elbow arthroplasty (TEA),which is an acceptable first-linetreatment in the elderly and low-demand patient populations, should

be viewed only as a salvage option inthe young, active patient because ofthe increased demands placed acrossthe implant throughout the patient’slifetime.3 These demands may arisebecause of inability or unwillingnessto adhere to activity restrictions re-quired for TEA, which otherwisemay be associated with an unaccept-ably high mechanical failure rate.Therefore, in this patient population,the goals of surgery are to provide aminimally painful and functional el-bow articulation while maintainingfuture salvage options.

Patient Evaluation

History and PhysicalExaminationHistory of the initial elbow injuryshould include mechanism of injury,

Benjamin W. Sears, MD

Gabor J. Puskas, MD

Mark E. Morrey, MD

Joaquin Sanchez-Sotelo, MD

Bernard F. Morrey, MD

From St. Anthony’s North Hospital,Westminster, CO (Dr. Sears), theDepartment of Orthopaedics,Division of Shoulder and ElbowSurgery, University of Zurich,Balgrist University Hospital, Zurich,Switzerland (Dr. Puskas), and theDepartment of Orthopedic Surgery,Division of Shoulder and ElbowSurgery, Mayo Clinic, Rochester,MN (Dr. Mark E. Morrey,Dr. Sanchez-Sotelo, and Dr. BernardF. Morrey).

Dr. Sanchez-Sotelo or an immediatefamily member has receivedroyalties from Stryker and hasreceived research or institutionalsupport from Stryker, DePuy, andZimmer. Dr. Bernard F. Morrey or animmediate family member hasreceived royalties from SBI andDonJoy and serves as a paidconsultant to or is an employee ofTenex Health and Zimmer. None ofthe following authors or anyimmediate family member hasreceived anything of value from orhas stock or stock options held in acommercial company or institutionrelated directly or indirectly to thesubject of this article: Dr. Sears,Dr. Puskas, and Dr. Mark E. Morrey.

J Am Acad Orthop Surg 2012;20:704-714

http://dx.doi.org/10.5435/JAAOS-20-11-704

Copyright 2012 by the AmericanAcademy of Orthopaedic Surgeons.

Review Article

704 Journal of the American Academy of Orthopaedic Surgeons

type of fractures or instability, subse-quent treatment, and history of in-fection. Previous surgical reportsshould be obtained to determineprior exposures, nerve transposition,hardware, and complications. Atreatment plan is then establishedthrough assessment of the primarypatient complaint as it relates topain, stiffness, or instability. If painis the primary complaint, the sur-geon should determine whether thepatient has pain at terminal motion(ie, impingement), throughout theentire arc of motion, and/or at rest.Impingement-type pain secondary toosteophyte formation or capsularcontracture can limit the arc of mo-tion. Generally, pain throughout theentire arc of motion indicates a jointwith a damaged bearing surface andadvanced degenerative changes. Thiscan be associated with night pain, ef-fusions, and progressive stiffness.Pain at rest is approached withcaution regardless of radiographicchanges because it may representnonarticular pain such as infection,cervical spine radicular pain, soft-tissue disease, or reflex sympatheticdystrophy.1

The elbow should be examined fordeformity, swelling, drainage, crepi-tus, and previous surgical incisions.For patients with compromised soft-tissue envelopes and previous flapcoverage, knowledge of pedicledflaps is essential for surgical inter-vention.4 Vascular and neurologic eval-uation should include assessment of ul-nar nerve irritability, subluxation, andsensory and motor function. Assess-ment of the arc of motion, includinglevel and location of pain, is comparedwith that of the contralateral elbow. Fi-nally, muscle strength and collateral lig-ament stability are evaluated. An accu-rate characterization of normal andpathologic elbow structures is impor-tant to guide treatment planning. Thekey is to determine which clinical fea-ture is most limiting for the patient so

that the best option for that patientmay be offered.

Imaging and OtherComplementary TestsConventional radiographs, consist-ing of two orthogonal views of theelbow (ie, AP, lateral), are the stan-dard initial evaluation for posttrau-matic osseous deformity. Plain radio-graphs demonstrate the extent ofdegenerative disease and can detectsubtle degenerative changes, includ-ing osteophyte formation, loose bod-ies, and joint space narrowing.5 Inone study, advanced radiographicchanges were associated with worseoutcome measures at 65 months fol-lowing débridement of primary el-bow osteoarthritis.6

CT is more accurate and hasgreater interobserver agreement thanconventional radiography in detect-ing osteophytes and loose bodies.7

CT arthrography allows evaluationof cartilage lesions and soft-tissuepathology.8 Three-dimensional re-construction CT has gained popular-ity as a tool for visualizing osteo-phyte distribution and assessing

complex deformity patterns whenplanning surgical débridement.9,10 Al-though MRI is useful for evaluatingsoft tissues, its clinical utility in theposttraumatic osteoarthritic elbowhas not been demonstrated, and it isnot routinely required.

In patients with peripheral neurop-athies, an electromyographic evalua-tion is obtained to provide a baselinefor assessing prognosis of nerve func-tion recovery. Ruling out infection isparamount before surgery. In the set-ting of possible septic arthritis, it isnecessary to perform elbow aspira-tion to determine cell count with dif-ferential and cultures. In patientswith previous open injuries, historyof prior infection, associated non-union, or a worrisome clinical pre-sentation, preoperative testing andplanning are required to check forpotential infection. Perioperativetesting should include peripheralblood cell count, erythrocyte sedi-mentation rate, and C-reactive pro-tein level, as well as intraoperativecultures and pathology, and the sur-geon and patient have to be preparedfor potentially staged procedures.

AP (A) and lateral (B) radiographs demonstrating posttraumatic osteoarthritisof the elbow following distal humerus fracture.

Figure 1

Benjamin W. Sears, MD, et al

November 2012, Vol 20, No 11 705

Management

The mainstay of early treatment of theyoung patient with posttraumatic ar-thritis consists of maintaining joint mo-bility and reducing activities that placestress across the elbow, such as weightbearing and repetitive motions.1

Nonsurgical measures may be defini-tive for mild arthrosis, and they canbe used as a temporizing measureprior to surgical intervention in per-sons with advanced arthritis. Non-steroidal anti-inflammatory drugsand selective intra-articular cortico-steroid injections can control pain

and facilitate daily use of the ar-thritic elbow. Temporary pain reliefhas been reported with intra-articular injections of sodium hy-aluronate; however, after 6 monthsthere are no discernible benefits, andit is not currently approved by theUS Food and Drug Administrationfor use in the elbow.11

For patients who fail nonsurgicaltreatment, surgical management shouldbe directed at restoring elbow functionand reducing pain (Figure 2). Based onour experience with posttraumatic el-bow arthritis, we have concluded thatpatients with stiffness and pain at ter-

minal motion (ie, impingement) maybenefit from open or arthroscopic os-teocapsular joint débridement. Whenpatients report pain throughout the en-tire arc of motion and advanced degen-erative disease is evident on imaging, itmay be appropriate to consider jointresurfacing with interposition arthro-plasty or partial joint arthroplasty. Pa-tients who have failed all other treat-ment measures may be candidates fortotal joint arthroplasty, as long as re-strictions associated with implants (ie,10 lb per single lift, <2 to 5 lb for re-petitive lifting) and the likelihood of fu-ture revision are accepted by the pa-

Treatment algorithm for posttraumatic elbow arthritis in the young patient whose primary complaint is stiffness withterminal pain or pain throughout the entire range of motion.EMG = electromyography, TEA = total elbow arthroplastya Ulnar nerve concerns

Figure 2

Posttraumatic Elbow Arthritis in the Young Adult: Evaluation and Management


tient and the surgeon. The goal oftreatment is to restore a functional jointwhile preserving future surgical salvageoptions. Here, we review managementoptions from the simplest to the morecomplex.

Options for ImpingementPain, Loose Bodies, andStiffnessDiminished motion in the earlystages of posttraumatic osteoarthritisis consistent with extrinsic elbowcontracture. This is characterized bythe presence of periarticular osteo-phytes but no major articular carti-lage degeneration. Clinically, patientswith extrinsic elbow contracture re-port pain at terminal motion (ie, im-pingement) and limited discomfortalong the midarc of motion.2 Whennonsurgical measures have failed,options for surgical management in-clude either arthroscopic or opentechniques.

Surgical goals include removal ofloose bodies and osteophytes, subtotalcapsulectomy, selective release of theposterior bundle of the medial collat-eral ligament to increase flexion, andpreservation of the anterior bundle ofthe medial collateral ligament and lat-eral collateral ligament complex. Spe-cial consideration should be given tothe ulnar nerve, which, when not ad-dressed, can play a major role in faileddébridement. Currently, we have a verylow threshold for in situ decompressionof the ulnar nerve with joint débride-ment, and we recommend transposi-tion in patients with preoperative ulnarneuropathy or <90° of flexion (Figure3).

ArthroscopyTechnical advances in elbow arthros-copy have made it increasingly popu-lar for the management of posttrau-matic extrinsic elbow contracture.Krishnan et al12 reported improve-ment in the flexion-extension arc

from 60° preoperatively to 133° fol-lowing arthroscopic ulnohumeral ar-throplasty in 11 patients youngerthan 50 years. The authors reportedno major neurovascular complica-tions and complete patient satisfac-tion at a minimum 2-year follow-up.Other investigations of arthroscopicosteocapsular elbow release haveyielded similar results, includinggood or excellent objective results inapproximately 80% of patients13 us-ing several intraoperative variations,including olecranon fenestration,14

radial head resection,15 and capsulec-tomy.16

Cohen et al17 compared the openOuterbridge-Kashiwagi procedure witharthroscopic débridement and fenestra-tion of the olecranon fossa. They foundboth procedures to be effective, withborderline significance for superior mo-tion gain following the open procedureand with better pain relief following ar-throscopy. The Outerbridge-Kashiwagiprocedure utilized a midline posteriorincision with a triceps split allowing forinitial débridement of the posteriorcompartment. Fenestration of the olec-ranon fossa was then performed, al-lowing for transhumeral débridementof the anterior elbow compartment.DeGreef et al14 found comparableresults between the arthroscopicOuterbridge-Kashiwagi procedure andtheir open technique. Although resultsof open and arthroscopic osteocap-sular débridement have been describedin younger patients with primaryOA (mean age, approximately 50years),10,12,13,16,18-20 there is a paucityof results on patients with posttrau-matic arthritis.14,21 However, these re-sults likely can be extrapolated to thetreatment of young posttraumaticpatients without articular surface de-struction or pain throughout the arcof motion.

Open TechniquesSeveral successful surgical options ex-ist for open release of extrinsic elbow

contracture, including arthrolysis,22

osteocapsular débridement,10 the col-umn procedure,21 and ulnohumeralarthroplasty.18 Cikes et al22 reportedon arthrolysis for posttraumatic ex-trinsic or mixed elbow contracture in18 patients with an average age of36 years. Motion improved from 82°preoperatively to 122° postopera-tively, with 94% patient satisfactionat mean follow-up of 16 months. Inpatients with extrinsic elbow con-tracture, Mansat and Morrey21 re-ported good or excellent results in82% of patients following débride-ment and capsular release with thecolumn procedure, including im-provement in the flexion-extensionarc from 49° preoperatively to 94° ata mean of 43 months postopera-tively. Although the underlying diag-nosis in this study was mixed, thetreatment principles still apply.

The column procedure utilizes alimited lateral approach to the ante-rior and posterior capsule along thelateral supracondylar osseous ridge(ie, lateral column). Anteriorly, thefleshy origin of the flexor carpi radi-alis longus and the distal part of thebrachioradialis are released. Posteri-orly, the triceps is elevated from thedistal humerus and the posterior cap-sule. The anterior and posterior cap-sules are resected and all osteophytesdébrided. The lateral ulnar collateralligament is preserved.

Ulnohumeral arthroplasty may bean option for patients with extensiveosteophytes in the olecranon andcoronoid fossa.18 This modificationof the Outerbridge-Kashiwagi proce-dure incorporates olecranon fossafenestration and allows ulnar nerverelease through the same approach inpatients with preoperative ulnar neu-ropathy or flexion limited to <90° to100°.19 In long-term follow-up stud-ies of open ulnohumeral arthroplasty(mean, 80 to 85 months), good toexcellent results were achieved in ap-proximately 80% of patients, with



an increased flexion-extension arc of16° to 22°.19,20 Arthroscopic andopen techniques have shown successin the initial management of extrinsicelbow contracture associated withearly stages of posttraumatic osteoar-thritis.

Options for AddressingDamaged Joint SurfacesSevere joint destruction typicallypresents with pain throughout the

entire arc of motion and with radio-graphic joint space narrowing. Thesefindings are consistent with ad-vanced disease and effectively trans-late into a “bad bearing” joint. It isthe authors’ opinion that arthros-copy can be used to define the extentof degenerative changes in these pa-tients but that it typically does notprovide definitive improvement inpain or motion. Joint arthroplasty mayresult in the most predictable pain re-

lief and improved joint motion; how-ever, functional restrictions and con-cern about deterioration over time limitthe use of TEA in most young patientswith posttraumatic elbow arthritis. Al-ternative resurfacing options withfewer restrictions may be employed asalternative procedures that still reserveTEA as a future salvage alternative.These options include partial joint ar-throplasty and biologic interpositionarthroplasty.

A, Intraoperative photographdemonstrating in situ decompressionof the ulnar nerve (asterisk) at thetime of osteocapsular arthroplasty.The ulnar nerve lies along the medialhead of the triceps. B, This samelimited skin incision provides accessfor formal resection of theposteromedial capsule and theposterior band of the medial collateralligament (MCL). In this photograph,the knife is releasing the posteriorband of the MCL, which serves as thefloor of the cubital tunnel. The ulnarnerve (asterisk) is protected by theretractor. C, The procedure iscompleted arthroscopically.

Figure 3



Isolated Radiocapitellar orDistal Humeral Joint DiseaseIn young patients, isolated arthritisof the radiocapitellar articulation orthe articular surface of the distal hu-merus commonly results from frac-ture malunion, nonunion, or carti-lage injury.2 Patients with isolatedradiocapitellar arthritis typically re-port lateral-sided elbow pain andlimited and/or painful forearm rota-tion.2 For young patients with symp-tomatic posttraumatic radiocapitel-lar degenerative disease who havefailed extensive nonsurgical treat-ment, surgical options other thanTEA include radial head resection,limited biologic interposition arthro-plasty, and prosthetic replacement ofthe capitellum and/or radial head.

Radial Head ResectionAlthough radial head resection effec-tively removes the arthritic surface inpatients with radiocapitellar degener-ative changes, the long-term effect oftransferring force transmission en-tirely through the ulnohumeral artic-ulation is unknown. This consider-ation may be especially important inthe young patient given the possiblepropagation or development of ul-nohumeral arthrosis. In spite of con-

cern for the development of ul-nohumeral arthritis, few data areavailable to determine the clinicalimpact of altered joint forces follow-ing radial head resection. Antuñaet al23 retrospectively reviewed 26patients following radial head resec-tion for radial head fractures withoutinstability. At the time of surgery, allpatients were younger than 40 years.Follow-up was a minimum of 15years after surgery. The authors re-ported that, although osteoarthriticradiographic changes were uniformlypresent, 92% of patients had satis-factory results with no associatedfunctional impairment. Although in-formation reported in the setting ofan acute radial head fracture doesnot necessarily translate to patientswith an arthritic joint, isolated resec-tion of the radial head remains at-tractive because it is easy to performand does not require the use of im-plants or biologic resurfacing.

Partial Interposition ArthroplastyInterposition arthroplasty of the ra-diocapitellar joint is another alterna-tive that does not require prostheticimplants. We have been impressedwith the clinical results obtained

with interposition of the anconeusmuscle into the radiohumeral joint.In this procedure, the radial head isexcised, and the anconeus muscle isreflected from its distal insertion,taking care to preserve its neurovas-cular integrity, after which the an-coneus is rotated into the radiocapi-tellar articulation underneath thelateral collateral ligament complex.This also increases stability throughligament tensioning (Figure 4). Clini-cal data have demonstrated this to bea useful procedure in patients withan arthritic capitellum and associ-ated radiohumeral impingement orrotatory radioulnar impingement;however, interposition arthroplastydoes not provide axial stability.24

Partial Joint ArthroplastyProsthetic replacement of the ar-thritic bearing surface may also beconsidered. Isolated radial head re-placement removes the diseased ar-ticulation, restores lateral columnstability in patients with valgus lax-ity, and rebalances force distributionacross the elbow joint. However, anisolated radial head implant de-creases radiocapitellar contact areaby an average of 68% compared

Intraoperative photographs of anconeus interposition arthroplasty. A, The anconeus muscle has been dissected andprepared for interposition. B, The anconeus has been passed underneath the collateral ligament complex to beinterposed in the radiohumeral joint.

Figure 4



with the native radiocapitellar joint,which may result in further capitellardegenerative changes.25 To addressthis, a radiocapitellar system may beused to replace both the capitellumand the radial head26 (Figure 5, A).In addition to resurfacing the ar-thritic articulation, capitellar resur-facing hemiarthroplasty maintainsexternal rotation and valgus stabilityof the lateral joint compared withcapitellar excision.27,28 However, iso-lated capitellar replacement is cur-rently an off-label application, andthere are limited data to judge clini-cal outcomes following radiocapitel-lar replacement. In the only currentoutcome study, Heijink et al29 re-ported on a case series of three pa-tients who underwent radiocapitellarprosthetic implantation. All three pa-tients had a functional implant withno signs of dissociation or looseningat a mean follow-up of 83 months.Although further research is requiredto determine the utility of radiocapi-tellar replacement, this procedureprovides an option for resurfacing anarthritic articulation and helps re-store lateral joint stability.

Distal humerus hemiarthroplastymay be done in cases of degenerativechanges that primarily involve thedistal humerus (Figure 5, B). Thistechnique, which involves resurfac-ing of the humeral articulation withpreservation of the native ulnar artic-ulating surface, has been describedfor the management of acute distalhumeral fracture, nonunion, andfailed fixation.28 However, definitiveoutcomes data are limited for pa-tients with posttraumatic arthritis. Inaddition, as with isolated capitellarreplacement, distal humeral hemiar-throplasty is an off-label applicationof the implant. In a review of datafrom the Mayo Clinic Joint Replace-ment Database, Steinmann28 foundthat patients undergoing hemiarthro-plasty reported an average Mayo El-bow Performance Score (MEPS) of74.5 but had a 16.7% revision ratewith relatively short-term follow-up.Adolfsson and Nestorson30 reportedan 88% satisfactory rate (seven ofeight patients) in low-demand elderlypatients treated with humeral hemi-arthroplasty. One patient had an ul-nar periprosthetic fracture 3 years

postoperatively. Although this proce-dure is rarely required, it is an optionfor patients with distal humeral pa-thology following fracture malunionor nonunion.

Interposition ArthroplastyInterposition arthroplasty, whichuses autograft material (eg, fascialata, cutis) or allograft material (eg,Achilles tendon, dermis) to resurfacethe elbow articulating surface, pro-vides an alternative to TEA in theyoung, high-demand patient31 (Fig-ure 6). Proponents of this proceduresee interposition as a viable treat-ment option for this population, inparticular, because it does not carrythe postoperative use and weight-bearing restrictions recommended af-ter TEA. In addition, and perhapsmore important, with interpositionarthroplasty, there are several recon-struction options available, includinganother interposition arthroplasty orTEA.32,33

Elbow interposition arthroplasty isindicated for painful loss of motionin the young or active patient whowants to avoid the functional restric-tions of TEA.34 Contraindications in-clude gross instability or deformity,active infection, open physes, andabsence of flexor motor power.1 Inaddition, inadequate elbow bonestock and elbow pain at rest areassociated with suboptimal out-comes.31,35 For patients with thesecomplicating factors, partial or totaljoint arthroplasty may result in supe-rior outcomes and should be consid-ered despite the associated functionallimitations and concern regarding re-vision procedures (Figure 2). Defor-mity and instability must be ad-dressed in either instance.

Possibly because of the technicallydemanding nature of the procedure, thefrequency with which interposition ar-throplasty is performed is unknown.However, posttraumatic arthritis ap-pears to be a leading diagnosis. Celli

A, Lateral radiograph demonstrating partial unicompartmental radiocapitellarjoint arthroplasty. B, Lateral radiograph demonstrating distal humerushemiarthroplasty.

Figure 5



and Morrey3 reported that posttrau-matic arthritis accounted for 71% ofthe 133 interposition arthroplastiesperformed at Mayo Clinic over a 20-year period. An age distribution wasnot included in their data. Larsonand Morrey31 found the same per-centage in a group averaging 39years of age.

Range of motion and outcomescores demonstrate improvement inpatients undergoing interposition ar-throplasty; however, these results areinferior to those following joint ar-throplasty.1 Cheng and Morrey35 re-ported on 10 patients with painfulbut mobile posttraumatic arthritis ofthe elbow following biologic interpo-sition arthroplasty using fascia lata.The postoperative success rate was70%; however, three patients re-quired revision to TEA at a mean of30 months. Nolla et al36 reported on13 patients with severe posttrau-matic elbow arthrosis who under-went interposition arthroplasty andtemporary hinged external fixation.Although the mean postoperativeBroberg-Morrey score and motionimproved markedly, four patients(31%) were found to have severepostoperative instability attributedto bone loss. The authors concludedthat although interposition arthro-plasty can improve elbow motionand function, it might come at theexpense of elbow stability.

In the largest published series todate, Larson and Morrey31 reported on38 elbows managed with Achilles ten-don allograft interposition arthroplastyat a mean 6-year follow-up (mean pa-tient age, 39 years; 76% posttraumaticdiagnosis). Although the mean MEPSimproved from 41 points preopera-tively to 65 points postoperatively andthe mean flexion-extension arc im-proved from 51° to 97°, 11 patients(29%) had a poor result, and 7 (18%)required revision surgery. Additionally,11 patients with preoperative instabil-ity were found to have a significantly

lower MEPS despite collateral ligamentreconstruction. Even so, 88% of all pa-tients indicated they would have theprocedure again. The authors con-cluded that, although interposition el-bow arthroplasty is a salvage proce-dure that neither eliminates pain norrestores full function, it might be indi-cated for young, active patients with se-

vere arthritis and limited elbow motionand no associated elbow instability.

Despite the relatively modest re-sults reported in the literature, one ofthe most attractive features of inter-position arthroplasty is that it doesnot compromise subsequent salvageprocedures. Larson et al33 reportedon nine patients with severe post-

A and B, Intraoperative photographs of Achilles tendon allograft used inelbow interposition arthroplasty. Three or four drill holes are created in aposterior-to-anterior direction across the distal humerus, and the preparedgraft is securely attached to the humerus with suture through these osseoustunnels. The ulnohumeral joint is subsequently reduced over the graft, andcollateral ligament primary repair is completed. If the collaterals are deemedinsufficient, the implanted allograft can be used to reconstruct both bythreading a strand of the graft through a single drill hole in the ulna, creatinga collateral sling. AP (C) and lateral (D) radiographs following elbowinterposition arthroplasty with a hinged external fixator.

Figure 6



traumatic arthritis undergoing revi-sion of a failed interposition arthro-plasty with another interpositionprocedure using Achilles tendon al-lograft. Only one patient had a poorresult, and five were satisfied withthe revision procedure. The authorsconcluded that this is an option foryoung, active patients with severeposttraumatic arthritis who requireboth mobility and durability of theelbow. In a separate study, Blaineet al32 demonstrated that conversionof failed interposition arthroplasty toTEA can be performed successfullywith reliable pain relief and a satis-factory result in most patients. Inthat study, 10 of 12 patients reportedmild or no pain with satisfactory re-sults at a mean of 9.9 years follow-ing conversion. Interposition arthro-plasty has moderately successfulresults, enables elbow use with fewrestrictions, and preserves the abilityfor subsequent salvage options.

Total Elbow ArthroplastyTEA remains the most definitivefunctional procedure for end-stageosteoarthritis. However, there is hesi-tation regarding implantation ofTEA in the posttraumatic populationbecause of implant overuse and in-creased bone-cement stresses associ-ated with relatively high failure rates.Schneeberger et al37 reported on 41patients with posttraumatic elbowarthrosis who were managed withsemiconstrained TEA (average age,57 years). A major complication wasreported in 27% of patients, and22% of all patients in the series re-quired additional surgery. Most com-plications resulted from mechanicalfailure, including bushing wear andulnar component fracture. They con-cluded that because of the mechani-cal failures encountered in this popu-lation, this procedure is relativelycontraindicated for patients who an-ticipate strenuous physical activity or

who are not expected to comply withpostoperative restrictions.

Mechanical failures become moreconcerning in the young patient un-dergoing TEA for posttraumatic ar-thritis because of patient longevityand increased physical demands (Fig-ure 7). In a follow-up study, Throck-morton et al38 examined failure pat-terns in 84 patients (85 TEAs)treated with semiconstrained TEA tomanage posttraumatic arthritis. Me-chanical wear, consisting of bushingwear and component loosening orfracture, was the primary reason forintermediate- and late-term failure.Notably, 75% of failures in thisstudy occurred in patients who wereyounger than 60 years of age at thetime of surgery. Celli and Morrey3

reported on the results of 55 semi-constrained TEAs performed in pa-tients aged ≤40 years, including 19patients who underwent TEA forposttraumatic arthritis. Although theauthors reported a satisfactory out-come based on the MEPS in 84% ofpatients with posttraumatic arthritis,the rate of revision as a result of acomplication was 37%.

In some cases, TEA may be theonly treatment option. This typicallyoccurs because of severe injury suchas massive bone loss, articular dis-ruption, or failure of other treatmentoptions. If TEA is required, implan-tation with a linked or unlinked de-sign should be considered. An un-linked prosthesis, which has nomechanical linkage between the hu-meral and ulnar components, may beadvantageous for the young patientwith a stable articulation becausethere are lesser bone-cement inter-face stresses than with linked im-plants. In unlinked TEA, stability isachieved with implant geometry andsoft-tissue balancing rather thanwith the intrinsic constraint of thearticulation.39 When properly posi-tioned and balanced, these implants aredesigned to restore near-normal elbow

A, AP radiograph demonstrating a successful outcome 5 years after totalelbow arthroplasty. B, Lateral radiograph demonstrating failed total elbowarthroplasty secondary to wear. Notice the absence of osteolysis orloosening.

Figure 7



kinematics and allow load-sharing be-tween implant and soft tissues, dimin-ish implant stresses, and, theoretically,reduce loosening rates.40 However,loosening can occur with unlinkedimplants, and results deteriorate overtime.1,38 Additionally, inability to bal-ance surrounding soft tissues is acontraindication for these devices.Thus, unlinked implants are rarelyemployed for posttraumatic condi-tions, regardless of patient age. Theuse of so-called convertible designsthat allow for conversion betweenlinked and unlinked articulationwith the same implant may providethe greatest variety of options. Im-plant longevity and the potentialneed for subsequent revision surgeryare important considerations in TEAin the young patient.

ArthrodesisElbow arthrodesis is rarely indicatedbecause the adjacent joints do notcompensate for motion loss. How-ever, arthrodesis may be an optionfor young patients with posttrau-matic unilateral arthrosis who re-quire a strong and stable joint.41 Fu-sion may be obtained using a varietyof techniques, including bent plates,compression screws, external fixa-tion, and crossed tibial bone grafts.Complications are relatively uncom-mon and include nonunion and frac-ture. Although fusion can create astable and strong articulation, for theyoung patient, we recommend othersalvage options before resorting toarthrodesis because of the resultingprofound functional limitations.

Summary

Osteoarthritic changes of the elboware commonly encountered in theyounger patient following traumaticinjury. Although TEA represents themost definitive functional procedurefor the management of end-stage os-

teoarthritis, in this population it isassociated with a concerning inci-dence of complications and failuresfrom increased activity demands andpotential implant duration. There-fore, TEA should be considered to bea salvage procedure in this patientpopulation.

Management of posttraumatic el-bow arthritis begins with extensive,long-term, nonsurgical symptomaticcare. For patients who fail nonsurgi-cal treatment, surgical options areaimed at restoring a functional el-bow joint with manageable pain lev-els (Figure 2). The patient whose pri-mary report is stiffness and pain atterminal motion may benefit fromarthroscopic or open osteocapsulardébridement. Patients with advanceddegenerative changes and pain alongthe entire arc of motion may be con-sidered for joint resurfacing with ei-ther interposition arthroplasty orpartial joint arthroplasty.

Patients who have failed all othermeasures may be candidates for TEA,with the strict understanding of thephysical limitations required for thisoption and the likelihood of revision inthe future. Unlinked implants may helpdisperse mechanical stresses from thecement-bone interface to that of the na-tive tissues, theoretically promotinglongevity. However, in practice, pa-tients commonly present with severebone loss, deformity, and ligament in-competency, which makes implantationof unlinked implants difficult andfraught with complications. The pri-mary goal of treatment in the youngpatient with posttraumatic elbow ar-thritis is to restore a minimally painfulbut functional joint while preservingfuture surgical salvage options.

References

Evidence-based Medicine: Levels ofevidence are described in the table ofcontents. In this article, references 5,

11, 19, and 22 are level III studies.References 3, 4, 6-10, 13-18, 20, 21,23, 24, 26, 28-38, and 41 are levelIV studies.

References printed in bold type arethose published within the past 5years.

1. Cheung EV, Adams R, Morrey BF:Primary osteoarthritis of the elbow:Current treatment options. J Am AcadOrthop Surg 2008;16(2):77-87.

2. Wysocki RW, Cohen MS: Primaryosteoarthritis and posttraumatic arthritisof the elbow. Hand Clin 2011;27(2):131-137, v.

3. Celli A, Morrey BF: Total elbowarthroplasty in patients forty years of ageor less. J Bone Joint Surg Am 2009;91(6):1414-1418.

4. Jensen M, Moran SL: Soft tissuecoverage of the elbow: A reconstructivealgorithm. Orthop Clin North Am 2008;39(2):251-264, vii.

5. Dalal S, Bull M, Stanley D: Radiographicchanges at the elbow in primaryosteoarthritis: A comparison withnormal aging of the elbow joint.J Shoulder Elbow Surg 2007;16(3):358-361.

6. Rettig LA, Hastings H II, Feinberg JR:Primary osteoarthritis of the elbow: Lackof radiographic evidence for morpho-logic predisposition, results of operativedebridement at intermediate follow-up,and basis for a new radiographic classifi-cation system. J Shoulder Elbow Surg2008;17(1):97-105.

7. Zubler V, Saupe N, Jost B, PfirrmannCW, Hodler J, Zanetti M: Elbowstiffness: Effectiveness of conventionalradiography and CT to explain osseouscauses. AJR Am J Roentgenol 2010;194(6):W515-W520.

8. Singson RD, Feldman F, Rosenberg ZS:Elbow joint: Assessment with double-contrast CT arthrography. Radiology1986;160(1):167-173.

9. Lim YW, van Riet RP, Mittal R, BainGI: Pattern of osteophyte distribution inprimary osteoarthritis of the elbow.J Shoulder Elbow Surg 2008;17(6):963-966.

10. Wada T, Isogai S, Ishii S, Yamashita T:Débridement arthroplasty for primaryosteoarthritis of the elbow. J Bone JointSurg Am 2004;86(2):233-241.

11. van Brakel RW, Eygendaal D: Intra-articular injection of hyaluronic acid isnot effective for the treatment of post-traumatic osteoarthritis of the elbow.Arthroscopy 2006;22(11):1199-1203.



12. Krishnan SG, Harkins DC, PenningtonSD, Harrison DK, Burkhead WZ:Arthroscopic ulnohumeral arthroplastyfor degenerative arthritis of the elbow inpatients under fifty years of age.J Shoulder Elbow Surg 2007;16(4):443-448.

13. Kelly EW, Bryce R, Coghlan J, Bell S:Arthroscopic debridement without radialhead excision of the osteoarthritic elbow.Arthroscopy 2007;23(2):151-156.

14. DeGreef I, Samorjai N, De Smet L: TheOuterbridge-Kashiwaghi procedure inelbow arthroscopy. Acta Orthop Belg2010;76(4):468-471.

15. Savoie FH III, Nunley PD, Field LD:Arthroscopic management of thearthritic elbow: Indications, technique,and results. J Shoulder Elbow Surg 1999;8(3):214-219.

16. Adams JE, Wolff LH III, Merten SM,Steinmann SP: Osteoarthritis of theelbow: Results of arthroscopicosteophyte resection and capsulectomy.J Shoulder Elbow Surg 2008;17(1):126-131.

17. Cohen AP, Redden JF, Stanley D:Treatment of osteoarthritis of the elbow:A comparison of open and arthroscopicdebridement. Arthroscopy 2000;16(7):701-706.

18. Morrey BF: Primary degenerativearthritis of the elbow: Treatment byulnohumeral arthroplasty. J Bone JointSurg Br 1992;74(3):409-413.

19. Antuña SA, Morrey BF, Adams RA,O’Driscoll SW: Ulnohumeralarthroplasty for primary degenerativearthritis of the elbow: Long-termoutcome and complications. J Bone JointSurg Am 2002;84(12):2168-2173.

20. Tashjian RZ, Wolf JM, Ritter M, WeissAP, Green A: Functional outcomes andgeneral health status after ulnohumeralarthroplasty for primary degenerativearthritis of the elbow. J Shoulder ElbowSurg 2006;15(3):357-366.

21. Mansat P, Morrey BF: The columnprocedure: A limited lateral approach for

extrinsic contracture of the elbow.J Bone Joint Surg Am 1998;80(11):1603-1615.

22. Cikes A, Jolles BM, Farron A: Openelbow arthrolysis for posttraumaticelbow stiffness. J Orthop Trauma 2006;20(6):405-409.

23. Antuña SA, Sánchez-Márquez JM, BarcoR: Long-term results of radial headresection following isolated radial headfractures in patients younger than fortyyears old. J Bone Joint Surg Am 2010;92(3):558-566.

24. Morrey BF, Schneeberger AG: Anconeusarthroplasty: A new technique forreconstruction of the radiocapitellarand/or proximal radioulnar joint. J BoneJoint Surg Am 2002;84(11):1960-1969.

25. Liew VS, Cooper IC, Ferreira LM,Johnson JA, King GJ: The effect ofmetallic radial head arthroplasty onradiocapitellar joint contact area. ClinBiomech (Bristol, Avon) 2003;18(2):115-118.

26. Tomaino MM: The emerging role forUni-Elbow arthroplasty. Am J Orthop(Belle Mead NJ) 2008;37(8 suppl 1):26-28.

27. Sabo MT, Shannon HL, Deluce S, et al:Capitellar excision and hemiarthroplastyaffects elbow kinematics and stability.J Shoulder Elbow Surg 2012;21(8):1024-1031, e4.

28. Steinmann SP: Hemiarthroplasty of theulnohumeral and radiocapitellar joints.Hand Clin 2011;27(2):229-232, vi.

29. Heijink A, Morrey BF, Cooney WP III:Radiocapitellar hemiarthroplasty forradiocapitellar arthritis: A report of threecases. J Shoulder Elbow Surg 2008;17(2):e12-e15.

30. Adolfsson L, Nestorson J: The Kudohumeral component as primaryhemiarthroplasty in distal humeralfractures. J Shoulder Elbow Surg 2012;21(4):451-455.

31. Larson AN, Morrey BF: Interpositionarthroplasty with an Achilles tendonallograft as a salvage procedure for the

elbow. J Bone Joint Surg Am 2008;90(12):2714-2723.

32. Blaine TA, Adams R, Morrey BF: Totalelbow arthroplasty after interpositionarthroplasty for elbow arthritis. J BoneJoint Surg Am 2005;87(2):286-292.

33. Larson AN, Adams RA, Morrey BF:Revision interposition arthroplasty of theelbow. J Bone Joint Surg Br 2010;92(9):1273-1277.

34. Morrey BF: Post-traumatic contractureof the elbow: Operative treatment,including distraction arthroplasty. J BoneJoint Surg Am 1990;72(4):601-618.

35. Cheng SL, Morrey BF: Treatment of themobile, painful arthritic elbow bydistraction interposition arthroplasty.J Bone Joint Surg Br 2000;82(2):233-238.

36. Nolla J, Ring D, Lozano-Calderon S,Jupiter JB: Interposition arthroplasty ofthe elbow with hinged external fixationfor post-traumatic arthritis. J ShoulderElbow Surg 2008;17(3):459-464.

37. Schneeberger AG, Adams R, Morrey BF:Semiconstrained total elbow replacementfor the treatment of post-traumaticosteoarthrosis. J Bone Joint Surg Am1997;79(8):1211-1222.

38. Throckmorton T, Zarkadas P, Sanchez-Sotelo J, Morrey B: Failure patterns afterlinked semiconstrained total elbowarthroplasty for posttraumatic arthritis.J Bone Joint Surg Am 2010;92(6):1432-1441.

39. An KN: Kinematics and constraint oftotal elbow arthroplasty. J ShoulderElbow Surg 2005;14(1 suppl s):168S-173S.

40. Gramstad GD, King GJ, O’Driscoll SW,Yamaguchi K: Elbow arthroplasty usinga convertible implant. Tech Hand UpExtrem Surg 2005;9(3):153-163.

41. Bilic R, Kolundzic R, Bicanic G,Korzinek K: Elbow arthrodesis after warinjuries. Mil Med 2005;170(2):164-166.



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