ULNOHUMERAL ARTHROPLASTY AS TREATMENT OF PRIMARY OSTEOARTHRITIS OF THE ELBOW: INDICATIONS, TECHNIQUE AND RESULTS Samuel A. Antuna M.D PhD Deparment of Orthopedic Surgery Hospital Universitario La Paz Madrid Spain
Etiology: Primary Osteoarthritis of the Elbow (POE) is an overuse syndrome affecting manual workers, athletes or disabled people requiring continuous use of crutches. More common in males in the mid 50´s. It is not posttraumatic!!. Pathology: Typically the joint is well preserved and there is characteristic formation of osteophytes in the tips of the olecranon and coronoid, obliteration of the olecranon fossa, and intraarticular loose bodies (60% cases). Ulnohumeral joint space is not usually severely affected!!!. Signs and Symptoms: Since the joint space is ok, there is no pain with midarc motion. Initial presentation is usually with flexion contracture and pain at the end points of motion (impingement pain), more in extension. Commonly associated with locking and ulnar nerve symptoms (up to 50% of cases). Some patients complain mainly of stiffness.
Diagnosis: It can be made based solely on the clinical presentation and on the characteristic radiographic findings: Osteophytes, loose bodies, ossification of the olecranon fossae. No need for CT scan or MRI!!.
Treatment: Remember the joint surfaces are normally preserved, so very rarely there is indication for resurfacing or elbow replacement. 1976: Outerbridge-Kashiwagi procedure with fenestration of the olecranon fossa and removal of loose bodies and osteophytes through a triceps splitting approach. Modified by Morrey in 1992 as Ulnohumeral Arthroplasty (UA): use of a Threphine to make the humeral fenestration and triceps sparing approach.
Steps: 1.Posterior incision. 2. Examination of the ulnar nerve. 3.Triceps splitting or sparing depending on muscle volume. 4. Removal of olecranon osteophyte and posterior loose bodies. 5 Humeral fenestration with 16 mm threphine (Cloward). 6 Extraction of anterior loose bodies with finger. 7. Seven millimetres osteotome to remove the coronoid osteophyte.
Additional gestures not always required but important to remember: Column Procedure if severe stiffnes preoperatively or if stiffness is the main complain; Ulnar nerve transposition when preoperative symptoms present and also if there is a severe preoperative flexion deficit (high risk of nerve streching)!!!!.
Results: 46 elbows reviewed at a mean of 6.5 years (1): - 78% no or mild pain - 22º of increased motion as average (significantly more if column associated) - 34 elbows with an excellent or good result according to MEPS. - 13 (28%) complained of ulnar nerve symptoms and six required further surgery to address the nerve !!! Conclusion: UHA is a good option for patients with POE. It is the cornerstone to which other techniques should compare. Arthroscopic techniques may play an important role in experienced hands. Great attention must be paid to the ulnar nerve and we should be prepared to move if nerve symptoms or severe flexion lack preoperatively.
References:
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