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Arthroscopic Treatment of the Arthritic Elbow Due to Primary Radiocapitellar Arthritis
Arthroscopic Treatment of the Arthritic Elbow Due to Primary Radiocapitellar Arthritis Robert E. McLaughlin II, M.D., Felix H. Savoie III, M.D., Larry D. Field, M.D., and J. Randall Ramsey, M.D.
Purpose: To retrospectively compare patients who received radial head excision for early, isolated radiocapitellar arthritis with those who had delayed surgery for the same problem in order to analyze risk factors for progression of the arthritis. Isolation of risk factors for progression should allow guidelines for early excision and perhaps prevent progression to panarticular arthritis. Type of Study: Retrospective analysis of a group of patients with radiocapitellar arthritis. Methods: From 1995 to 2001, 36 consecutive patients with arthritic damage to the radiocapitellar joint were treated with arthroscopic debridement and radial head excision. Twenty-eight of the 36 underwent concurrent arthroscopic modification of the Outerbridge-Kashiwagi procedure because of the additional presence of ulnohumeral arthritis. All patients were re-examined 18 to 91 months (mean, 52 months) after the procedure and evaluated using the Andrews-Carson (A-C) elbow rating system. Results: In patients who underwent radial head excision alone, flexion increased 29°, extension 38°, with an increase in total arc of motion of 62°. In patients who underwent radial head excision and ulnohumeral arthroplasty, postoperative flexion increased 19°, extension 27°, with an increase in total arc of motion of 46°. The difference between the 2 groups of patients was significant (P ⫽ .002). The average preoperative A-C score for patients undergoing radial head excision alone was 72 and the average postoperative score was 170. The average preoperative score for patients undergoing radial head excision and ulnohumeral arthroplasty was 92 and the average postoperative score was 150. Two patients who underwent the combined procedure had to return to surgery: 1 for a contracture release and 1 for radial head replacement secondary to intractable pain. They both did well subsequently Conclusions: Patients undergoing radial head excision alone increased their average A-C score almost 100 points. Those undergoing both procedures increased their score an average of 58 points. In addition, those undergoing only radial head excision had a 20-point higher average overall postoperative A-C rating than those undergoing both procedures. Patients who underwent radial head excision alone had a greater return of range of motion and fewer postoperative complications than those who underwent the combined procedure. Level of Evidence: Level IV. Key Words: Radial head—Radial capitellar arthritis—Elbow arthroscopy—Ulnohumeral arthroplasty.
R
adiocapitellar arthritis is a problem that causes pain and loss of motion and function. The etiology is multifactorial, including post-traumatic, degen-
From the Upper Extremity Service, Mississippi Sports Medicine & Orthopaedic Center (R.E.M., F.H.S., L.D.F., J.R.R.); and the Department of Orthopaedic Surgery, University of Mississippi School of Medicine (F.H.S., L.D.F.), Jackson, Mississippi, U.S.A. Address correspondence and reprint requests to Felix H. Savoie III, M.D., 1325 East Fortification St, Jackson, MS 39202, U.S.A. E-mail: [email protected] © 2006 by the Arthroscopy Association of North America 0749-8063/06/2201-3987$32.00/0 doi:10.1016/j.arthro.2005.10.013
erative, and inflammatory arthritis. Conservative treatment consists of anti-inflammatory medications and injections, physical therapy, and bracing.1 More aggressive treatment ranges from debridement and excision of osteophytes, synovium, and loose bodies to replacement surgery.2 Traditionally, radial head excision and/or debridement has been performed open, but recent advances in arthroscopic instrumentation and techniques have introduced a new treatment option for patients with an arthritic elbow.3-20 Previously we have reported on the efficacy of the arthroscopic Outerbridge-Kashiwagi procedure for panarticular arthritis both with and without radial head excision.21 In this
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 22, No 1 (January), 2006: pp 63-69
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study, we attempted to look retrospectively at only those patients with initial radiocapitellar injury problems and in whom radial head excision was necessary. In treating these patients, it was postulated that these individuals, who had radiocapitellar arthritis and who delayed excision of their arthritic radial head, had progression of their arthritis and would experience inferior outcomes after excision of their radial head. We report on a consecutive series of 36 patients with the primary diagnosis of radiocapitellar arthritis who underwent either early arthroscopic excision of the radial head alone (8 patients) or late arthroscopic radial head excision combined with ulnohumeral arthroplasty (28 patients). These patients were selected based on the initiating area of arthritis being in the radiocapitellar joint, and were selected from a database of over 200 arthritic elbows. METHODS In a retrospective review of patients undergoing radial head excision because of an initial problem with the radiocapitellar joint, we found 36 consecutive patients with arthritic damage to the radiocapitellar joint in whom a fully arthroscopic debridement and radial head excision had been carried out. Eight patients (group I) had only radial head excision whereas 28 of the 36 underwent a concurrent arthroscopic modification of the Outerbridge-Kashiwagi procedure. All patients had failed a course of conservative therapy that consisted of nonsteroidal anti-inflammatory medication, injection, physical therapy, and protective bracing to offload the radiocapitellar for a period of at least 3 months. The average patient age was 45.7 years (range, 26 to 68 years), and there were 18 male and 18 female patients. There were 23 right elbows and 13 left elbows. The arthritic changes were caused by posttraumatic radial head fracture degenerative arthritis in 17 patients, primary osteoarthritis beginning with radiocapitellar joint in 10 patients, rheumatoid arthritis with radiocapitellar subluxation in 3 patients, arthrofibrosis in 2 patients, and osteonecrosis, psoriatic arthritis, post–radial head fracture synostosis, and acute radial head fracture in 1 patient each. In the group of patients undergoing arthroscopic radial head excision alone, preoperative flexion was to 112° (range, 90° to 140°) and average extension loss was ⫺38° (range, ⫺60° to ⫺15°). The average total arc of motion was 74°. All patients were evaluated both preoperatively and postoperatively using the Andrews-Carson (A-C) rat-
FIGURE 1. View from the medial portal with the shaver in the lateral portal debriding osteophytes from the coronoid process.
ing scale8 as well as the visual analog scale (VAS) for pain. Patients were asked to report on satisfaction, perceived success of the procedure, and VAS scale. All patients were re-evaluated 18 to 91 months after the operation. Surgical Technique In this procedure, we place the patient in the prone position. A block is placed under the arm to elevate it away from the arm board, and the forearm and hand are allowed to hang free with the elbow flexed at 90°. The elbow is initially entered through an anterior proximal medial portal, and anterior proximal lateral instrument portal is then established. Loose bodies and arthritic debris are removed, and an anterior synovectomy is performed. Osteoarthritic spurs are debrided from the coronoid process (Fig 1). The anterior aspect of the radial head is then excised with the shaver in the lateral portal (Fig 2). The cutting surface of the shaver should be kept facing in a posterior direction to protect the posterior interosseous nerve, which lies adjacent to the anterior capsule at this level. Penetration of the capsule in this area could potentially damage the nerve. The arthroscope is left in the anterior proximal medial portal, a freer retractor is inserted through the proximal anterior lateral portal to hold the anterolateral capsule away from the radial head and thereby protect the posterior interosseous/radial nerve, and the posterior lateral soft spot is used for instrumentation. This portal is established by placing a spinal
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FIGURE 2. Viewing from the medial portal with the shaver in the lateral portal removing the anterior aspect of the radial head.
FIGURE 4. Viewing from the medial portal after resection of the radial head.
needle in the posterior lateral soft spot and passed between the radial head and capitellum (Fig 3). The spinal needle is then removed and replaced with a flexible cannula. The shaver is placed through the cannula and swept medially and laterally to excise the radial head until adequate clearance is obtained, usually 5 to 8 mm (Fig 4). The proximal radioulnar joint is then assessed and additional bone removed if necessary. The extent of radial head excision may be further evaluated by fluoroscopy during this stage of the process. The inflow is left anteriorly in the proximal medial portal and the arthroscope is introduced through a
standard posterolateral portal. The posterior central portal is used for instrumentation, and the olecranon fossa is debrided of arthritic spurs and loose bodies. The tip of the olecranon and associated spurs are then excised until 0° to 5° of extension is achieved (Fig 5). The medial gutter is debrided of synovium with care being taken to keep the hooded aspect of the shaver always directed toward the ulnar nerve and medial capsule. The suction is turned off in this area while the debridement is carried out. The lateral gutter is then debrided with excision of the posterolateral plica. The radial head and proximal radioulnar joint are re-evaluated from this portal.
FIGURE 3. Viewing from the medial portal after excision of the anterior portion of the radial head: The spinal needle in passed in the posterior lateral soft spot between the radial head and the capitellum to mark the entry site of the burr.
FIGURE 5. Viewing from the posterior lateral portal with the burr in the direct posterior portal, the tip of the olecranon is resected until 0° to 5° of extension is achieved.
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FIGURE 6. Viewing from the posterior lateral portal with the drill in the direct posterior portal, the drill is centered in the olecranon fossa and drilled through to connect with the coronoid fossa.
FIGURE 7. Viewing from the posterior lateral portal with the burr in the direct posterior portal, the hole in the olecranon fossa is enlarged to at least 2 cm in diameter.
RESULTS In the Outerbridge-Kashiwagi procedure, attention is then focused to the olecranon fossa. A 5-mm drill is placed through the posterior portal with the arthroscope in the posterolateral portal. The drill is centered in the olecranon fossa and drilled from back to front until the olecranon fossa is connected with the coronoid fossa. The drill is centered in the olecranon fossa and angled toward the center of the coronoid fossa, paying careful attention not to plunge the drill bit because vital neurovascular structures lie anteriorly (Fig 6). The intersection of the long axis of the humerus with the inflow cannula in the anterior proximal medial portal serves as a guide for the proper orientation of the drill. After the location and depth of this channel connecting the 2 fossae are assessed, an arthroscopic burr is used to enlarge the hole to at least 2 cm in diameter or until full flexion (⬎135°) and extension (⬍5°) have been made possible (Fig 7). The procedure ends when the medial and lateral columns of the distal humerus are encountered. After the procedure has been completed, a suction drain is placed in the anterior portal and soft bandages applied. Continuous passive motion is started in recovery and is continued for at least the first week. In elbows with longstanding contractures, it may be necessary to splint them temporarily in either flexion or extension. All patients receive physical therapy instruction for home exercises while in the hospital and are encouraged to use the elbow as tolerated.
All patients had both preoperative and postoperative A-C rating scales (Table 1). In the group of patients undergoing arthroscopic radial head excision, debridement, and ulnohumeral arthroplasty, preoperative flexion was to 112° (range, 90° to 140°) and average extension loss was ⫺33° (range, 10° to 70°). The average total arc of motion was 79°. The average preoperative A-C score for patients undergoing radial excision alone was 72 (range, 65-100) points while those undergoing both procedures averaged 92 (range, 40-125). All patients were re-examined 18 to 91 months (mean, 52 months) after the procedure. In patients who underwent radial head excision alone (group I), postoperative flexion averaged 141° (range, 140° to 145°) and postoperative extension loss averaged 0°. Flexion increased 29°, extension 38°, with an increase in total arc of motion of 62°. In patients who underwent radial head excision and ulnohumeral arthroplasty (group II), postoperative flexion averaged 131° (range, 100° to 145°) and postoperative extension loss averaged 6° (average, 0° to TABLE 1. Group I Group II Excellent Good Fair Poor
Andrews-Carson Rating Scale (radial head excision) (radial head and ulnohumeral arthroplasty) 180-120 160-179 120-159 ⬍120
PRIMARY RADIOCAPITELLAR ARTHRITIS TABLE 2.
Andrews-Carson Scores
A-C Scale
Group I Preop
Group I Postop
Group II Preop
Group II Postop
Excellent 180-200 Good 160-179 Fair 120-159 Poor ⬍120
0 0 0 8
1 6 1 0
0 0 4 24
2 6 18 2
20°). Flexion increased 19°, extension 27°, with an increase in total arc of motion of 46°. The difference between the 2 groups of patients was significant (P ⫽ .002). The average preoperative A-C score for patients who underwent radial head excision alone was 72 points (range, 65-100) and the average postoperative score was 170 (range, 155-180). The average preoperative A-C score for patients who underwent radial head excision and ulnohumeral arthroplasty alone was 92 points (range, 40-125) and the average postoperative score was 150 (range, 90-185) (Table 2). All of the 8 patients who underwent radial head excision alone reported significant (decrease of 2 or more levels on VAS scale) pain relief and were satisfied with the procedure. Twenty-six of the 28 patients who underwent ulnohumeral arthroplasty and radial head excision also reported significant pain relief and were satisfied with the procedure. Two patients who underwent the combined procedure had to return to surgery, 1 for a contracture release and 1 for radial head replacement secondary to intractable pain. They both subsequently achieved satisfactory A-C ratings and were satisfied with their end result. DISCUSSION Nonoperative management works well for most patients with mild to moderate arthritis of the radiocapitellar joint and elbow. In certain patients, significant deformity develops leading to pain, loss of motion, and a decreased functional ability. In these patients, there are relatively few procedures that improve function and decrease pain. Resection of the radial head in this group is currently the only alternative to prosthetic replacement. Arthroscopy for radiocapitellar degeneration and elbow arthritis has many advantages over open surgery. First, it allows for complete removal of intraarticular loose bodies and debris, thickened synovial fluid, and inflamed synovium, a procedure that may retard the progression of the arthritis. Removal of
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bone spurs and large loose bodies may also provide transient relief of symptoms and improve function. Accomplishing this without open surgery that detaches the musculotendinous unit allows immediate range of motion and strengthening of the elbow. Our results show a greater increase in range of motion than the open surgical series reported by Kashiwagi22 and Morrey.23 Although difficult to compare, this better result may represent an advantage of the arthroscopic procedure. Known complications associated with resection of the radial head include neurovascular damage, cubitus valgus, loss of strength, myositis ossificans, and heterotopic ossification.24 Fortunately, none was reported in our study. Open elbow debridement has been described by Stanley and Winson25 but they presented no results or follow-up information. Open and/or arthroscopic resection of the radial head to treat radiocapitellar arthritis has been well described in the literature with excellent results. Open and arthroscopic olecranon fenestration with or without additional debridement has similarly been shown to have satisfactory results.14,17-19,22,23,25-29 Taylor et al.30 reported an average increase in elbow flexion/extension of only 20° after open radial head excision. We report an average increase of 62°, significantly more than that reported by the open procedure. This may be attributable to decreased soft-tissue morbidity associated with arthroscopy, allowing for less scar formation and contracture. Another reason may be the ability of the arthroscopic procedure to address pathology throughout the joint without additional incisions. Patients who underwent radial head excision alone had a greater return of range of motion than those who underwent the combined procedure. Both groups had similar flexion-extension loss preoperatively, but the group with only radial head excision increased an average of 62°, whereas those with the combined procedure averaged only 46°. These results were statistically significant (P ⫽ .002). Patients who underwent radial head excision alone had an average preoperative A-C score of 72 points and an average postoperative score of 170. Those undergoing both procedures had an average preoperative score of 92 and postoperative score of 150. We believe that this is a significant finding. Patients undergoing radial head excision alone increased their average A-C almost 100 points, going from a rating of poor to good. Those undergoing both procedures only increased their score an average of 58 points. In ad-
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dition, those undergoing only radial head excision had a 20-point higher average overall postoperative A-C rating than those undergoing both procedures, while starting at a lower functional level. We consider that this information suggests that patients treated early in the disease process had greater success overall than those who chose to receive later treatment. It also suggests that a more significant improvement in function is found in patients treated early. Twenty-six of the 28 patients undergoing the combined procedure had good relief of pain and return of function. Two patients had to return to surgery. The first patient developed a flexion contracture after surgery and was treated with aggressive physical therapy with no improvement for a period of 6 months. He subsequently underwent an arthroscopic capsular release and did well postoperatively with good pain relief and return of range of motion and A-C score of 190. The second patient had rheumatoid arthritis and had continued pain after excision of the radial head. He complained of wrist and elbow pain and had developed proximal migration of the radial shaft. He underwent radial head replacement and subsequently achieved a satisfactory result. This complication highlights the fact that, before radial head excision (arthroscopic or open), it is important to assess the integrity of the distal radioulnar joint by physical examination of the distal radioulnar joint and interosseous membrane. Damage in these areas can allow for proximal migration of the radial head, resulting in altered wrist and/or elbow kinematics. Both of these complications occurred in patients undergoing the combined surgical procedure. This suggests an increased risk of excessive scar formation and damage to the supporting structures of the elbow with a more aggressive procedure, further emphasizing the possible benefit from earlier resection of the radial head. We believe that the statistically significant difference in results between group I and group II is a direct result of earlier intervention in the disease process. In all of these patients, the initiating factor in the development of functionally disabling arthritis was radiocapitellar problems. Although a majority of patents with radial head fractures and radiocapitellar disease respond well to nonoperative management, these patients did not. The symptoms of the patients in this study were characterized by an increased perception of pain on the VAS scale, an early, severe, and persistent loss of motion, and a fairly rapid progression of the arthritis to include the remainder of the elbow joint as compared with other patients with radiocapitellar
FIGURE 8. These are the type of radial head injuries that seem to warrant early excision or replacement: (A) A mushroom-shaped radial head deformity and (B) posterior subluxation.
injuries. The initial injuries of the study group did not seem to be markedly different than those usually producing isolated radial head fractures. However, radiographically there seemed to be 2 major differences noted in this series of patients. In most of them, the radial head deformity was distinctly mushroom shaped or expansile. We also often noted a slight posterior subluxation on the lateral radiograph of the radial head on the capitellum (Fig 8). One additional midterm finding was early onset of changes to the posterior aspect of the radiocapitellar joint. We would suggest that these observations may define a subset of patients who would be better managed by early, rather than delayed, radial head excision. However, because the present study is limited by its retrospective nature and does not attempt to follow all radiocapitellar injuries seen in our clinic, it must be stated that these
PRIMARY RADIOCAPITELLAR ARTHRITIS observations are not proven by the current results, but may prove useful as a guide to future investigations. This study serves to show that arthroscopic radial head excision provides an effective tool in the treatment of radiocapitellar arthritis. Results of arthroscopic radial head excision alone are superior to those of excision combined with an ulnohumeral arthroplasty and have shown in this limited study to have a lower incidence of complications. In the select group of patients with certain deformities of the radiocapitellar joint, early excision may prove to be more conservative then delayed excision. These deformities include the mushroom-shaped deformity, the posteriorly subluxated radial head, and the development of early postradiocapitellar squaring. We await further study of this hypothesis. CONCLUSIONS Patients undergoing radial head excision alone increased their average A-C score almost 100 points. Those undergoing both procedures increased their score an average of 58 points. In addition, those undergoing only radial head excision had a 20-point higher average overall postoperative A-C rating than those undergoing both procedures. Patients who underwent radial head excision alone had a greater return of range of motion and fewer postoperative complications than those who underwent the combined procedure. REFERENCES 1. Huckisson EC, Dieppe PA, Tucker AK, Cannell LB. Another look at osteoarthritis. Ann Rheum Dis 1979;38:423-428. 2. Smith FM. Surgery of the elbow. Ed 2. Philadelphia: WB Saunders, 1972. 3. Burman MS. Arthroscopy or the direct visualization of joints. An experimental cadaver study. J Bone Joint Surg 1931;13: 669-695. 4. Watanabe M. Arthroscopy of small joints. J Jpn Orthop Assoc 1971;45:908-915. 5. Maeda Y. Arthroscopy of the elbow joint. Arthroscopy 1980; 5:5-8. 6. Ito K. The arthroscopic anatomy of the elbow joint. Arthroscopy 1979;4:2-9. 7. Poehling GG, Whipple TL, Sisco L, Goldman B. Elbow arthroscopy: A new technique. Arthroscopy 1989;5:222-224.
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8. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy 1985;1:97-107. 9. Morrey BF. Arthroscopy of the elbow. Instr Course Lect 1986;35:102-107. 10. Morrey BF. Arthroscopy of the elbow. In: Morrey BF, ed. The elbow and its disorders. Philadelphia: WB Saunders, 1985; 114-121. 11. Guhl JF. Arthroscopy and arthroscopic surgery of the elbow. Orthopedics 1985;8:1290-1296. 12. O’Driscoll SW. Operative treatment of elbow arthritis. Curr Opin Rheumatol 1995;7:103-106. 13. Robla J, Hechtman KS, Uribe JW, Phillipon MS. Chondromalacia of the trochlear notch in athletes who throw. J Shoulder Elbow Surg 1996;5:69-72. 14. O’Driscoll SW. Elbow arthroscopy for loose bodies. Orthopedics 1992;15:855-859. 15. Gries PE, Halbrecht J, Plancher KD. Arthroscopic removal of loose bodies in the elbow. Orthop Clin North Am 1995;26: 679-689. 16. Menth-Chiari WA, Poehling GG, Ruch DS. Arthroscopic resection of the radial head. Arthroscopy 1999;15:226-230. 17. Menth-Chiari WA, Poehling GG, Ruch DS. Arthroscopic resection of the radial head: Clinical outcome in 12 patients. Arthroscopy 2001;17:918-923. 18. Ogilvie-Harris DJ, Gorton R, MacKay M. Arthroscopic treatment for posterior impingement in degenerative arthritis of the elbow. Arthroscopy 1995;11:437-443. 19. Redden JF, Stanley D. Arthroscopic fenestration for osteoarthritis. Arthroscopy 1993;9:12-19. 20. Baker CL, Brooks AA. Arthroscopy of the elbow. Clin Sports Med 1996;15:261–281. 21. Savoie FH, Nunley PD, Field LD. Arthroscopic management of the arthritic elbow: Indications, techniques, and results. J Shoulder Elbow Surg 1999;8:214-219. 22. Kashiwagi D. Osteoarthritis of the elbow joint: Intra-articular changes and the special operative procedure. OuterbridgeKashiwagi method. In: Kashiwagi D, ed. Elbow joint. New York: Elsevier, 1985;177-178. 23. Morrey BF. Primary degenerative arthritis of the elbow: Treatment by ulnohumeral arthroplasty. J Bone Joint Surg Br 1992; 74:409-413. 24. Morrey BF. Radial head fracture. In: Morrey BF, ed. The elbow and its disorders. Ed 2. Philadelphia: WB Saunders, 1993;383-404. 25. Stanley D, Winson IG. A surgical approach to the elbow. J Bone Joint Surg Br 1990;72:728-729. 26. Broberg MA, Morrey. Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am 1986;68:669-674. 27. Kim SJ, Kim HK, Lee JW. Arthroscopy for limitation of motion of the elbow. Arthroscopy 1995;11:680-683. 28. Morrey BF. Posttraumatic contracture of the elbow: Operative treatment, including distraction arthroplasty. J Bone Joint Surg Am 1990;72:601-618. 29. Thal R. Osteoarthritis. In: Savoie FH, Field LD, eds. Elbow arthroscopy. New York: Churchill Livingstone, 1996. 30. Taylor AR, Mukerjea SK, Rana NA. Excision of the head of the radius in rheumatoid arthritis. J Bone Joint Surg Br 1976; 58:485-487.
Purpose: To retrospectively compare patients who received radial head excision for early, isolated radiocapitellar arthritis with those who had delayed surgery for the same problem in order to analyze risk factors for progression of the arthritis. Isolation of risk factors for progression should allow guidelines for early excision and perhaps prevent progression to panarticular arthritis. Type of Study: Retrospective analysis of a group of patients with radiocapitellar arthritis. Methods: From 1995 to 2001, 36 consecutive patients with arthritic damage to the radiocapitellar joint were treated with arthroscopic debridement and radial head excision. Twenty-eight of the 36 underwent concurrent arthroscopic modification of the Outerbridge-Kashiwagi procedure because of the additional presence of ulnohumeral arthritis. All patients were re-examined 18 to 91 months (mean, 52 months) after the procedure and evaluated using the Andrews-Carson (A-C) elbow rating system. Results: In patients who underwent radial head excision alone, flexion increased 29°, extension 38°, with an increase in total arc of motion of 62°. In patients who underwent radial head excision and ulnohumeral arthroplasty, postoperative flexion increased 19°, extension 27°, with an increase in total arc of motion of 46°. The difference between the 2 groups of patients was significant (P ⫽ .002). The average preoperative A-C score for patients undergoing radial head excision alone was 72 and the average postoperative score was 170. The average preoperative score for patients undergoing radial head excision and ulnohumeral arthroplasty was 92 and the average postoperative score was 150. Two patients who underwent the combined procedure had to return to surgery: 1 for a contracture release and 1 for radial head replacement secondary to intractable pain. They both did well subsequently Conclusions: Patients undergoing radial head excision alone increased their average A-C score almost 100 points. Those undergoing both procedures increased their score an average of 58 points. In addition, those undergoing only radial head excision had a 20-point higher average overall postoperative A-C rating than those undergoing both procedures. Patients who underwent radial head excision alone had a greater return of range of motion and fewer postoperative complications than those who underwent the combined procedure. Level of Evidence: Level IV. Key Words: Radial head—Radial capitellar arthritis—Elbow arthroscopy—Ulnohumeral arthroplasty.
R
adiocapitellar arthritis is a problem that causes pain and loss of motion and function. The etiology is multifactorial, including post-traumatic, degen-
From the Upper Extremity Service, Mississippi Sports Medicine & Orthopaedic Center (R.E.M., F.H.S., L.D.F., J.R.R.); and the Department of Orthopaedic Surgery, University of Mississippi School of Medicine (F.H.S., L.D.F.), Jackson, Mississippi, U.S.A. Address correspondence and reprint requests to Felix H. Savoie III, M.D., 1325 East Fortification St, Jackson, MS 39202, U.S.A. E-mail: [email protected] © 2006 by the Arthroscopy Association of North America 0749-8063/06/2201-3987$32.00/0 doi:10.1016/j.arthro.2005.10.013
erative, and inflammatory arthritis. Conservative treatment consists of anti-inflammatory medications and injections, physical therapy, and bracing.1 More aggressive treatment ranges from debridement and excision of osteophytes, synovium, and loose bodies to replacement surgery.2 Traditionally, radial head excision and/or debridement has been performed open, but recent advances in arthroscopic instrumentation and techniques have introduced a new treatment option for patients with an arthritic elbow.3-20 Previously we have reported on the efficacy of the arthroscopic Outerbridge-Kashiwagi procedure for panarticular arthritis both with and without radial head excision.21 In this
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 22, No 1 (January), 2006: pp 63-69
63
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study, we attempted to look retrospectively at only those patients with initial radiocapitellar injury problems and in whom radial head excision was necessary. In treating these patients, it was postulated that these individuals, who had radiocapitellar arthritis and who delayed excision of their arthritic radial head, had progression of their arthritis and would experience inferior outcomes after excision of their radial head. We report on a consecutive series of 36 patients with the primary diagnosis of radiocapitellar arthritis who underwent either early arthroscopic excision of the radial head alone (8 patients) or late arthroscopic radial head excision combined with ulnohumeral arthroplasty (28 patients). These patients were selected based on the initiating area of arthritis being in the radiocapitellar joint, and were selected from a database of over 200 arthritic elbows. METHODS In a retrospective review of patients undergoing radial head excision because of an initial problem with the radiocapitellar joint, we found 36 consecutive patients with arthritic damage to the radiocapitellar joint in whom a fully arthroscopic debridement and radial head excision had been carried out. Eight patients (group I) had only radial head excision whereas 28 of the 36 underwent a concurrent arthroscopic modification of the Outerbridge-Kashiwagi procedure. All patients had failed a course of conservative therapy that consisted of nonsteroidal anti-inflammatory medication, injection, physical therapy, and protective bracing to offload the radiocapitellar for a period of at least 3 months. The average patient age was 45.7 years (range, 26 to 68 years), and there were 18 male and 18 female patients. There were 23 right elbows and 13 left elbows. The arthritic changes were caused by posttraumatic radial head fracture degenerative arthritis in 17 patients, primary osteoarthritis beginning with radiocapitellar joint in 10 patients, rheumatoid arthritis with radiocapitellar subluxation in 3 patients, arthrofibrosis in 2 patients, and osteonecrosis, psoriatic arthritis, post–radial head fracture synostosis, and acute radial head fracture in 1 patient each. In the group of patients undergoing arthroscopic radial head excision alone, preoperative flexion was to 112° (range, 90° to 140°) and average extension loss was ⫺38° (range, ⫺60° to ⫺15°). The average total arc of motion was 74°. All patients were evaluated both preoperatively and postoperatively using the Andrews-Carson (A-C) rat-
FIGURE 1. View from the medial portal with the shaver in the lateral portal debriding osteophytes from the coronoid process.
ing scale8 as well as the visual analog scale (VAS) for pain. Patients were asked to report on satisfaction, perceived success of the procedure, and VAS scale. All patients were re-evaluated 18 to 91 months after the operation. Surgical Technique In this procedure, we place the patient in the prone position. A block is placed under the arm to elevate it away from the arm board, and the forearm and hand are allowed to hang free with the elbow flexed at 90°. The elbow is initially entered through an anterior proximal medial portal, and anterior proximal lateral instrument portal is then established. Loose bodies and arthritic debris are removed, and an anterior synovectomy is performed. Osteoarthritic spurs are debrided from the coronoid process (Fig 1). The anterior aspect of the radial head is then excised with the shaver in the lateral portal (Fig 2). The cutting surface of the shaver should be kept facing in a posterior direction to protect the posterior interosseous nerve, which lies adjacent to the anterior capsule at this level. Penetration of the capsule in this area could potentially damage the nerve. The arthroscope is left in the anterior proximal medial portal, a freer retractor is inserted through the proximal anterior lateral portal to hold the anterolateral capsule away from the radial head and thereby protect the posterior interosseous/radial nerve, and the posterior lateral soft spot is used for instrumentation. This portal is established by placing a spinal
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FIGURE 2. Viewing from the medial portal with the shaver in the lateral portal removing the anterior aspect of the radial head.
FIGURE 4. Viewing from the medial portal after resection of the radial head.
needle in the posterior lateral soft spot and passed between the radial head and capitellum (Fig 3). The spinal needle is then removed and replaced with a flexible cannula. The shaver is placed through the cannula and swept medially and laterally to excise the radial head until adequate clearance is obtained, usually 5 to 8 mm (Fig 4). The proximal radioulnar joint is then assessed and additional bone removed if necessary. The extent of radial head excision may be further evaluated by fluoroscopy during this stage of the process. The inflow is left anteriorly in the proximal medial portal and the arthroscope is introduced through a
standard posterolateral portal. The posterior central portal is used for instrumentation, and the olecranon fossa is debrided of arthritic spurs and loose bodies. The tip of the olecranon and associated spurs are then excised until 0° to 5° of extension is achieved (Fig 5). The medial gutter is debrided of synovium with care being taken to keep the hooded aspect of the shaver always directed toward the ulnar nerve and medial capsule. The suction is turned off in this area while the debridement is carried out. The lateral gutter is then debrided with excision of the posterolateral plica. The radial head and proximal radioulnar joint are re-evaluated from this portal.
FIGURE 3. Viewing from the medial portal after excision of the anterior portion of the radial head: The spinal needle in passed in the posterior lateral soft spot between the radial head and the capitellum to mark the entry site of the burr.
FIGURE 5. Viewing from the posterior lateral portal with the burr in the direct posterior portal, the tip of the olecranon is resected until 0° to 5° of extension is achieved.
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FIGURE 6. Viewing from the posterior lateral portal with the drill in the direct posterior portal, the drill is centered in the olecranon fossa and drilled through to connect with the coronoid fossa.
FIGURE 7. Viewing from the posterior lateral portal with the burr in the direct posterior portal, the hole in the olecranon fossa is enlarged to at least 2 cm in diameter.
RESULTS In the Outerbridge-Kashiwagi procedure, attention is then focused to the olecranon fossa. A 5-mm drill is placed through the posterior portal with the arthroscope in the posterolateral portal. The drill is centered in the olecranon fossa and drilled from back to front until the olecranon fossa is connected with the coronoid fossa. The drill is centered in the olecranon fossa and angled toward the center of the coronoid fossa, paying careful attention not to plunge the drill bit because vital neurovascular structures lie anteriorly (Fig 6). The intersection of the long axis of the humerus with the inflow cannula in the anterior proximal medial portal serves as a guide for the proper orientation of the drill. After the location and depth of this channel connecting the 2 fossae are assessed, an arthroscopic burr is used to enlarge the hole to at least 2 cm in diameter or until full flexion (⬎135°) and extension (⬍5°) have been made possible (Fig 7). The procedure ends when the medial and lateral columns of the distal humerus are encountered. After the procedure has been completed, a suction drain is placed in the anterior portal and soft bandages applied. Continuous passive motion is started in recovery and is continued for at least the first week. In elbows with longstanding contractures, it may be necessary to splint them temporarily in either flexion or extension. All patients receive physical therapy instruction for home exercises while in the hospital and are encouraged to use the elbow as tolerated.
All patients had both preoperative and postoperative A-C rating scales (Table 1). In the group of patients undergoing arthroscopic radial head excision, debridement, and ulnohumeral arthroplasty, preoperative flexion was to 112° (range, 90° to 140°) and average extension loss was ⫺33° (range, 10° to 70°). The average total arc of motion was 79°. The average preoperative A-C score for patients undergoing radial excision alone was 72 (range, 65-100) points while those undergoing both procedures averaged 92 (range, 40-125). All patients were re-examined 18 to 91 months (mean, 52 months) after the procedure. In patients who underwent radial head excision alone (group I), postoperative flexion averaged 141° (range, 140° to 145°) and postoperative extension loss averaged 0°. Flexion increased 29°, extension 38°, with an increase in total arc of motion of 62°. In patients who underwent radial head excision and ulnohumeral arthroplasty (group II), postoperative flexion averaged 131° (range, 100° to 145°) and postoperative extension loss averaged 6° (average, 0° to TABLE 1. Group I Group II Excellent Good Fair Poor
Andrews-Carson Rating Scale (radial head excision) (radial head and ulnohumeral arthroplasty) 180-120 160-179 120-159 ⬍120
PRIMARY RADIOCAPITELLAR ARTHRITIS TABLE 2.
Andrews-Carson Scores
A-C Scale
Group I Preop
Group I Postop
Group II Preop
Group II Postop
Excellent 180-200 Good 160-179 Fair 120-159 Poor ⬍120
0 0 0 8
1 6 1 0
0 0 4 24
2 6 18 2
20°). Flexion increased 19°, extension 27°, with an increase in total arc of motion of 46°. The difference between the 2 groups of patients was significant (P ⫽ .002). The average preoperative A-C score for patients who underwent radial head excision alone was 72 points (range, 65-100) and the average postoperative score was 170 (range, 155-180). The average preoperative A-C score for patients who underwent radial head excision and ulnohumeral arthroplasty alone was 92 points (range, 40-125) and the average postoperative score was 150 (range, 90-185) (Table 2). All of the 8 patients who underwent radial head excision alone reported significant (decrease of 2 or more levels on VAS scale) pain relief and were satisfied with the procedure. Twenty-six of the 28 patients who underwent ulnohumeral arthroplasty and radial head excision also reported significant pain relief and were satisfied with the procedure. Two patients who underwent the combined procedure had to return to surgery, 1 for a contracture release and 1 for radial head replacement secondary to intractable pain. They both subsequently achieved satisfactory A-C ratings and were satisfied with their end result. DISCUSSION Nonoperative management works well for most patients with mild to moderate arthritis of the radiocapitellar joint and elbow. In certain patients, significant deformity develops leading to pain, loss of motion, and a decreased functional ability. In these patients, there are relatively few procedures that improve function and decrease pain. Resection of the radial head in this group is currently the only alternative to prosthetic replacement. Arthroscopy for radiocapitellar degeneration and elbow arthritis has many advantages over open surgery. First, it allows for complete removal of intraarticular loose bodies and debris, thickened synovial fluid, and inflamed synovium, a procedure that may retard the progression of the arthritis. Removal of
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bone spurs and large loose bodies may also provide transient relief of symptoms and improve function. Accomplishing this without open surgery that detaches the musculotendinous unit allows immediate range of motion and strengthening of the elbow. Our results show a greater increase in range of motion than the open surgical series reported by Kashiwagi22 and Morrey.23 Although difficult to compare, this better result may represent an advantage of the arthroscopic procedure. Known complications associated with resection of the radial head include neurovascular damage, cubitus valgus, loss of strength, myositis ossificans, and heterotopic ossification.24 Fortunately, none was reported in our study. Open elbow debridement has been described by Stanley and Winson25 but they presented no results or follow-up information. Open and/or arthroscopic resection of the radial head to treat radiocapitellar arthritis has been well described in the literature with excellent results. Open and arthroscopic olecranon fenestration with or without additional debridement has similarly been shown to have satisfactory results.14,17-19,22,23,25-29 Taylor et al.30 reported an average increase in elbow flexion/extension of only 20° after open radial head excision. We report an average increase of 62°, significantly more than that reported by the open procedure. This may be attributable to decreased soft-tissue morbidity associated with arthroscopy, allowing for less scar formation and contracture. Another reason may be the ability of the arthroscopic procedure to address pathology throughout the joint without additional incisions. Patients who underwent radial head excision alone had a greater return of range of motion than those who underwent the combined procedure. Both groups had similar flexion-extension loss preoperatively, but the group with only radial head excision increased an average of 62°, whereas those with the combined procedure averaged only 46°. These results were statistically significant (P ⫽ .002). Patients who underwent radial head excision alone had an average preoperative A-C score of 72 points and an average postoperative score of 170. Those undergoing both procedures had an average preoperative score of 92 and postoperative score of 150. We believe that this is a significant finding. Patients undergoing radial head excision alone increased their average A-C almost 100 points, going from a rating of poor to good. Those undergoing both procedures only increased their score an average of 58 points. In ad-
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dition, those undergoing only radial head excision had a 20-point higher average overall postoperative A-C rating than those undergoing both procedures, while starting at a lower functional level. We consider that this information suggests that patients treated early in the disease process had greater success overall than those who chose to receive later treatment. It also suggests that a more significant improvement in function is found in patients treated early. Twenty-six of the 28 patients undergoing the combined procedure had good relief of pain and return of function. Two patients had to return to surgery. The first patient developed a flexion contracture after surgery and was treated with aggressive physical therapy with no improvement for a period of 6 months. He subsequently underwent an arthroscopic capsular release and did well postoperatively with good pain relief and return of range of motion and A-C score of 190. The second patient had rheumatoid arthritis and had continued pain after excision of the radial head. He complained of wrist and elbow pain and had developed proximal migration of the radial shaft. He underwent radial head replacement and subsequently achieved a satisfactory result. This complication highlights the fact that, before radial head excision (arthroscopic or open), it is important to assess the integrity of the distal radioulnar joint by physical examination of the distal radioulnar joint and interosseous membrane. Damage in these areas can allow for proximal migration of the radial head, resulting in altered wrist and/or elbow kinematics. Both of these complications occurred in patients undergoing the combined surgical procedure. This suggests an increased risk of excessive scar formation and damage to the supporting structures of the elbow with a more aggressive procedure, further emphasizing the possible benefit from earlier resection of the radial head. We believe that the statistically significant difference in results between group I and group II is a direct result of earlier intervention in the disease process. In all of these patients, the initiating factor in the development of functionally disabling arthritis was radiocapitellar problems. Although a majority of patents with radial head fractures and radiocapitellar disease respond well to nonoperative management, these patients did not. The symptoms of the patients in this study were characterized by an increased perception of pain on the VAS scale, an early, severe, and persistent loss of motion, and a fairly rapid progression of the arthritis to include the remainder of the elbow joint as compared with other patients with radiocapitellar
FIGURE 8. These are the type of radial head injuries that seem to warrant early excision or replacement: (A) A mushroom-shaped radial head deformity and (B) posterior subluxation.
injuries. The initial injuries of the study group did not seem to be markedly different than those usually producing isolated radial head fractures. However, radiographically there seemed to be 2 major differences noted in this series of patients. In most of them, the radial head deformity was distinctly mushroom shaped or expansile. We also often noted a slight posterior subluxation on the lateral radiograph of the radial head on the capitellum (Fig 8). One additional midterm finding was early onset of changes to the posterior aspect of the radiocapitellar joint. We would suggest that these observations may define a subset of patients who would be better managed by early, rather than delayed, radial head excision. However, because the present study is limited by its retrospective nature and does not attempt to follow all radiocapitellar injuries seen in our clinic, it must be stated that these
PRIMARY RADIOCAPITELLAR ARTHRITIS observations are not proven by the current results, but may prove useful as a guide to future investigations. This study serves to show that arthroscopic radial head excision provides an effective tool in the treatment of radiocapitellar arthritis. Results of arthroscopic radial head excision alone are superior to those of excision combined with an ulnohumeral arthroplasty and have shown in this limited study to have a lower incidence of complications. In the select group of patients with certain deformities of the radiocapitellar joint, early excision may prove to be more conservative then delayed excision. These deformities include the mushroom-shaped deformity, the posteriorly subluxated radial head, and the development of early postradiocapitellar squaring. We await further study of this hypothesis. CONCLUSIONS Patients undergoing radial head excision alone increased their average A-C score almost 100 points. Those undergoing both procedures increased their score an average of 58 points. In addition, those undergoing only radial head excision had a 20-point higher average overall postoperative A-C rating than those undergoing both procedures. Patients who underwent radial head excision alone had a greater return of range of motion and fewer postoperative complications than those who underwent the combined procedure. REFERENCES 1. Huckisson EC, Dieppe PA, Tucker AK, Cannell LB. Another look at osteoarthritis. Ann Rheum Dis 1979;38:423-428. 2. Smith FM. Surgery of the elbow. Ed 2. Philadelphia: WB Saunders, 1972. 3. Burman MS. Arthroscopy or the direct visualization of joints. An experimental cadaver study. J Bone Joint Surg 1931;13: 669-695. 4. Watanabe M. Arthroscopy of small joints. J Jpn Orthop Assoc 1971;45:908-915. 5. Maeda Y. Arthroscopy of the elbow joint. Arthroscopy 1980; 5:5-8. 6. Ito K. The arthroscopic anatomy of the elbow joint. Arthroscopy 1979;4:2-9. 7. Poehling GG, Whipple TL, Sisco L, Goldman B. Elbow arthroscopy: A new technique. Arthroscopy 1989;5:222-224.
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8. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy 1985;1:97-107. 9. Morrey BF. Arthroscopy of the elbow. Instr Course Lect 1986;35:102-107. 10. Morrey BF. Arthroscopy of the elbow. In: Morrey BF, ed. The elbow and its disorders. Philadelphia: WB Saunders, 1985; 114-121. 11. Guhl JF. Arthroscopy and arthroscopic surgery of the elbow. Orthopedics 1985;8:1290-1296. 12. O’Driscoll SW. Operative treatment of elbow arthritis. Curr Opin Rheumatol 1995;7:103-106. 13. Robla J, Hechtman KS, Uribe JW, Phillipon MS. Chondromalacia of the trochlear notch in athletes who throw. J Shoulder Elbow Surg 1996;5:69-72. 14. O’Driscoll SW. Elbow arthroscopy for loose bodies. Orthopedics 1992;15:855-859. 15. Gries PE, Halbrecht J, Plancher KD. Arthroscopic removal of loose bodies in the elbow. Orthop Clin North Am 1995;26: 679-689. 16. Menth-Chiari WA, Poehling GG, Ruch DS. Arthroscopic resection of the radial head. Arthroscopy 1999;15:226-230. 17. Menth-Chiari WA, Poehling GG, Ruch DS. Arthroscopic resection of the radial head: Clinical outcome in 12 patients. Arthroscopy 2001;17:918-923. 18. Ogilvie-Harris DJ, Gorton R, MacKay M. Arthroscopic treatment for posterior impingement in degenerative arthritis of the elbow. Arthroscopy 1995;11:437-443. 19. Redden JF, Stanley D. Arthroscopic fenestration for osteoarthritis. Arthroscopy 1993;9:12-19. 20. Baker CL, Brooks AA. Arthroscopy of the elbow. Clin Sports Med 1996;15:261–281. 21. Savoie FH, Nunley PD, Field LD. Arthroscopic management of the arthritic elbow: Indications, techniques, and results. J Shoulder Elbow Surg 1999;8:214-219. 22. Kashiwagi D. Osteoarthritis of the elbow joint: Intra-articular changes and the special operative procedure. OuterbridgeKashiwagi method. In: Kashiwagi D, ed. Elbow joint. New York: Elsevier, 1985;177-178. 23. Morrey BF. Primary degenerative arthritis of the elbow: Treatment by ulnohumeral arthroplasty. J Bone Joint Surg Br 1992; 74:409-413. 24. Morrey BF. Radial head fracture. In: Morrey BF, ed. The elbow and its disorders. Ed 2. Philadelphia: WB Saunders, 1993;383-404. 25. Stanley D, Winson IG. A surgical approach to the elbow. J Bone Joint Surg Br 1990;72:728-729. 26. Broberg MA, Morrey. Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am 1986;68:669-674. 27. Kim SJ, Kim HK, Lee JW. Arthroscopy for limitation of motion of the elbow. Arthroscopy 1995;11:680-683. 28. Morrey BF. Posttraumatic contracture of the elbow: Operative treatment, including distraction arthroplasty. J Bone Joint Surg Am 1990;72:601-618. 29. Thal R. Osteoarthritis. In: Savoie FH, Field LD, eds. Elbow arthroscopy. New York: Churchill Livingstone, 1996. 30. Taylor AR, Mukerjea SK, Rana NA. Excision of the head of the radius in rheumatoid arthritis. J Bone Joint Surg Br 1976; 58:485-487.