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Outcomes of Elbow Arthroscopic Osteocapsular Arthroplasty
SCIENTIFIC ARTICLE
Outcomes of Elbow Arthroscopic Osteocapsular Arthroplasty Samuel E. Galle, MD,* John D. Beck, MD,† Raoul J. Burchette, MA, MS,‡ Neil G. Harness, MD§
Purpose To evaluate the results of elbow arthroscopic osteocapsular arthroplasty (AOA) and determine which factors influence the outcome in a large group of patients with primary osteoarthritis. Methods A consecutive series of 46 patients with elbow osteoarthritis underwent AOA by a single surgeon (N.G.H.) between December 2005 and January 2013. Thirty-one patients returned for a comprehensive physical examination an average of 3.4 years later. The outcomes measures included visual analog scale (VAS), Mayo Elbow Performance Scores (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH), and American Shoulder and Elbow Society (ASES) scores. Preoperative and postoperative continuous variables were compared and a multivariable regression analysis was performed. Results Thirty-one patients with a mean age of 48 years (range, 19e77 years) returned for final follow-up, including 27 men and 4 women. Statistically significant improvement was observed in extension deficit (24 before surgery to 12 after surgery), flexion (126 before surgery to 135 after surgery), visual analog scale (6.4 before surgery to 1.6 after surgery), and Mayo Elbow Performance Scores (57 [poor] before surgery to 88 [good] after surgery). Subjective scores included a mean postoperative Disabilities of the Arm, Shoulder, and Hand score of 13 and an American Shoulder and Elbow Society pain score of 40. No complications were noted at final follow-up. Conclusions Elbow AOA is a safe, efficacious treatment for patients with mild to moderate osteoarthritis. Our retrospective review found significant improvement in elbow motion, pain and clinical outcomes. (J Hand Surg Am. 2016;41(2):184e191. Copyright Ó 2016 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Arthroscopy, contracture, elbow, osteoarthritis.
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osteoarthritis affects up to 2% of the population and is 4 times more common in men than women.1,2 Stanley2 noted in his review of 1,000 consecutive patients an overall YMPTOMATIC PRIMARY ELBOW
From the *Department of Orthopaedic Surgery, University of California, Irvine Health, Irvine, CA; the †Proliance Hand, Wrist, and Elbow Physicians, Kirkland, WA; the ‡Southern California Permanente Medical Group, Pasadena; and the §Kaiser Permanente Orange County, Anaheim, CA. Received for publication April 30, 2015; accepted in revised form November 18, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Neil G. Harness, MD, Kaiser Permanente Orange County, Kraemer Medical Office 1, 3460 E. La Palma Ave., Anaheim, CA 92806; e-mail: [email protected]. 0363-5023/16/4102-0003$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.11.018
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prevalence of symptomatic elbow osteoarthritis in men over the age of 40 years of 3.5%. Individuals between 30 and 50 years old engaged in heavy manual labor are most affected.2e4 Common presentations include a loss of terminal extension and/or development of pain leading to functional limitations in activities of daily living. Conservative treatments commonly fail to relieve symptoms, and although total elbow arthroplasty is reliable in the management of moderate to severe rheumatoid arthritis and some cases of osteoarthritis, implant durability is limited and recipients must refrain from heavy lifting.5e8 This has led surgeons to seek alternative treatment options for those that fail nonsurgical management.
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Ulnohumeral or osteocapsular arthroplasty combines capsular release, synovectomy, osteophyte/loose body removal, and contouring of the humerus and ulna to reduce impingement and improve motion. Several studies have demonstrated that open ulnohumeral arthroplasty reliably relieves pain in the majority of patients.9e13 With the advancement of surgical equipment and techniques, arthroscopic osteocapsular arthroplasty (AOA) has become an option for patients with functionally limiting osteoarthritis of the elbow. This technique has the potential for less soft tissue trauma, allows for complete joint evaluation, and has been proven safe3; however, the number of reports on this surgical approach is limited. Savoie et al14 showed that arthroscopic ulnohumeral arthroplasty provided satisfactory results in 24 patients evaluated at an average of 32 months with a mean increase of 81 in arc of motion and a decrease in visual analog scale (VAS) pain score of 6.6. Krishnan et al15 reported on 11 patients who underwent arthroscopic ulnohumeral arthroplasty with an average of 26 months follow-up and found improvements in total range of motion (ROM), 73 , and pain, from 9.2 to 1.7 on a 10-point scale, where 10 is the worst pain. Adams et al16 reported on the results of 42 elbows after AOA and at a minimum of 2 years follow-up; 81% of patients noted good to excellent results. Elbow AOA has proven to be a safe and reliable procedure with the potential for improvement in function and pain. However, reports are limited, and the technique has not gained wide popularity owing to the challenging nature of the surgery, potential for serious complications, and small number of patients who present with primary elbow osteoarthritis. The degree of improvement in motion and pain varies widely between primary reports. Moreover, it is not clear which preoperative factors predict a favorable outcome following surgery. The objective of this study was to evaluate the results of elbow AOA and determine which factors influence the outcome in a large group of patients with primary osteoarthritis. MATERIALS AND METHODS After institutional review board approval was obtained, we conducted a retrospective cohort study of all patients at least 18 years of age who underwent elbow AOA at Kaiser Permanente Southern California from August 2005 to December 2013. A total of 46 patients were identified who underwent AOA by a single surgeon for symptomatic, mild to moderate, primary degenerative osteoarthritis of the elbow. J Hand Surg Am.
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During the course of the study, 2 patients died; 4 were no longer members of Kaiser Permanente, which precluded inclusion in the study based on institutional review board rules; 2 declined to participate; and 7 patients were lost to follow-up. This left 31 patients for final analysis. We included patients with symptomatic mild to moderate elbow osteoarthritis with or without loss of elbow motion. Exclusion criteria included inflammatory arthritides, arthritis related to osteochondritis dissecans, elbow instability, prior elbow fracture, prior anterior ulnar nerve transposition, and severe medical comorbidities precluding surgery. Data collection The preoperative evaluation was performed by the senior author (N.G.H.), which included a complete history and physical examination. Range of motion measurements were recorded for flexion, extension, supination, and pronation using a hand-held goniometer. Pain was quantitated using a VAS both before and after surgery.17 Pre- and postoperative function was determined using the Mayo Elbow Performance Scores (MEPS).18 Intraoperative elbow flexion and extension was measured at the completion of the procedure using a hand-held goniometer and reported with pre- and postoperative values for comparison. Patient charts were retrospectively reviewed to determine: age, sex, hand dominance, side of operation, tobacco use, workers’ compensation status, occupation, chief complaint, underlying diagnosis for elbow contracture, prior elbow surgery, ulnar neuritis, relation of pain to ROM, and medical comorbidities, including diabetes mellitus and body mass index (BMI). Radiographic evaluation was performed at the time of the initial evaluation, and arthritis was retrospectively graded according the Broberg-Morrey radiographic staging system.19 Patients included in the study were invited to return for a final evaluation performed by a resident (S.E.G.) or attending surgeon (N.G.H.) in a nonblinded fashion. The assessment included elbow appearance (scarring, areas of tenderness, portal complications), ulnar nerve irritability/subluxation, ROM, elbow stability, strength (biceps/triceps/extensor pollicis longus/flexor pollicis longus/first dorsal interroseous; grip; pinch), pain with ROM (midrange vs end range), sensibility, and vascular status (pulse: radial and ulnar). Stability was determined using varus/valgus laxity at 30 of flexion compared with the contralateral limb. Grip and pinch strengths were assessed using a Jamar grip tester, and results were averaged from 3 attempts. Motor strength was evaluated using standard manual motor testing by the examiner. Sensibility was Vol. 41, February 2016
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determined by 2-point discrimination with normal defined as 5 mm or less. Subjective pain was determined using VAS and American Shoulder and Elbow Society (ASES) pain scales. Subjective postoperative outcome of functional ability was evaluted using the Disability of the Arm, Shoulder, and Hand (DASH)20 and the ASES21,22 scores. American Shoulder and Elbow Society scores for both function and pain were analyzed independently and combined as discussed by John et al.23 Final outcome was determined using MEPS scoring classifications: excellent, greater than 89; good, 75 to 89; fair, 60 to 74; and poor, less than 60. All postoperative complications were noted, detailing ongoing symptoms. Surgical technique The operative technique for AOA was performed by N.G.H in all cases in a similar manner to that described by Blonna et al.24 After general endotracheal anesthesia, the patients were rotated into a prone position. A 4-portal (proximal anteromedial, anterolateral, direct posterior, and posterolateral) technique was used for complete elbow arthroscopic evaluation and treatment. Accessory portals were used for placement of arthroscopic retractors as necessary. In the anterior compartment, all osteophytes and loose bodies were removed. An anterior capsulotomy was performed in all cases. As with Blonna et al,24 the capsulotomy technique evolved during the course of the senior surgeon’s experience with the technique. Initially, this was achieved with an arthroscopic shaver and subsequently with an arthroscopic biter. A full capsulectomy was never performed. A direct posterior portal was then created along with a posterolateral portal. Osteophytes were removed from the olecranon fossa and tip of the olecranon. Both the posteromedial and the posterolateral gutters were also cleared of any loose bodies. Satisfactory olecranon bone excision was determined when the articular cartilage of the trochlea was visualized easily with the elbow in 45 of flexion. A posterior capsulotomy was performed in cases in which flexion could not be restored by anterior osteophyte excision alone. In cases requiring more extensive medial dissection and capsulotomy, an open approach was used to identify the ulnar nerve and protect it. In cases in which preoperative elbow flexion was less than 90 , the ulnar nerve was transposed through an open approach at the time of arthroscopy. In some of the ulnar nerve transposition cases, the posterior fibers of the medial collateral ligament were divided under direct visualization to improve elbow flexion. This was not consistently reported in the operative reports and was not included in the data analysis. J Hand Surg Am.
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Postoperative care All patients were placed in a soft dressing, and immediate motion was encouraged. Formal physical therapy began between 7 to 10 days after surgery and consisted of ROM exercises and nighttime extension splinting with a custom fabricated thermoplastic orthosis. If patients were unable to maintain motion or were not progressing appropriately by 6 weeks after surgery, they used a static progressive orthosis. (Joint Active Systems, Effingham, IL). The clinical criteria for incorporation of a static progressive orthosis in the rehabilitation regimen were not standardized, and 8 patients used the device during the study period. Static progressive orthosis fabrication was not analyzed as a factor in the surgical outcome. Continuous passive motion was not used by any of the patients. Statistical analysis Descriptive statistics were computed for pre- and postsurgical measures and of the changes from pre- to postoperative values. Relationships between categorical variables such as sex, hand dominance, and operative side were examined using chi-square tests. Paired t tests and Wilcoxon signed rank test were used to look for statistically significant changes from before to after surgery as well as before surgery to follow-up after surgery including at least 7 months of follow-up. We also used Pearson and Spearman correlations to examine change by sequence number to determine if there was evidence to suggest that procedural changes over time made any difference in the measured outcomes. Independent groups t tests and Wilcoxon rank sum tests were used to compare measured variables and changes in measured variables by specific procedural techniques (sharp vs shaver). All demographic, preoperative, and postoperative subjective/objective measures were evaluated for correlations to elucidate critical factors in the success of elbow AOA. Multivariable analysis Age, sex, diabetes status, smoker status, BMI, preoperative ROM, the number of prior surgeries, cubital tunnel release status, and the surgical technique (none, sharp/biter, or shaver) were included as candidate explanatory covariates for the long-term ROM outcome and MEPS. Pearson and Spearman correlations were used among the independent variables to check for possible dependencies and as a factor analysis with a varimax rotation requiring the eigenvalues to be greater than 0.8. Variables that loaded on the same rotated factors with weights greater than 0.4 were Vol. 41, February 2016
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further checked for explicit association by both the Pearson chi-square and the Fisher exact test for discrete values and analysis of variance and by the KruskalWallis test if one was continuous and one was discrete. The Pearson and Spearman correlations were used when both were continuous. Any significant associations were examined as interaction terms in the linear regression model. Furthermore, a best subsets selection process (maximizing R2 and also maximizing the adjusted R2) was used and the results were compared with a backward elimination of variables down to P < 0.15. RESULTS The final follow-up group of 31 patients consisted of 27 men and 4 women with an average age of 48 years (range, 19e77 years). Occupations included 21 sedentary jobs and 10 heavy manual activity jobs. The youngest patient was 19 years old and presented with osteoarthritis, which was related to an elbow dislocation as a child. There were 6 patients with type II diabetes mellitus, 5 patients that were using tobacco at the time of the operation, and none with a prior diagnosis of inflammatory arthropathy. The vast majority of patients were right-handed (97%), and the right side was the operative side in 84% of cases. Twenty-four patients had no prior surgery on the ipsilateral upper extremity, and 7 had various prior procedures including 1 prior elbow contracture release. Broberg-Morrey radiographic staging revealed 8 patients with grade 1, 21 with grade 2, and 2 with grade 3 osteoarthritis prior to surgical intervention. Follow-up averaged 41 months (range, 7e98 months). All patients had been treated with some form of conservative therapy including but not limited to nonsteroidal anti-inflammatories, physical therapy, and corticosteroid injections prior to surgery. The average total preoperative arc of motion was 102 (range, 43 e135 ) with an average flexion of 126 (range, 62 e150 ) and extension of 24 (range, 0 e46 ). All but 3 patients presented with limitation of ROM and pain. These 3 patients had a functional ROM, and their primary complaint was pain due to impingement. The average total intraoperative arc of motion was 133 (range, 90 e145 ) with an average flexion of 136 (range, 90 e150 ) and extension of 3 (range, 0 e15 ) (Table 1). After surgery, the average total arc of motion was 124 (range, 78 e150 ; P < .01) with an average flexion of 135 (range, 98 e152 ; P < .01) and extension of 12 (range, 0 e32 ; P < .01) (Table 2). The improvement in motion in each patient is represented in Figure 1. J Hand Surg Am.
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Patients 29 and 30 had small losses of motion, and patient 31 had no improvement in motion. Before surgery, all but 3 patients had pain as their main functional limitation with 23 patients having terminal extension pain, 4 with midarc pain, and 1 with pain throughout the ROM. Final average scores were reported and include the following. The VAS improved significantly from 6.4 (range, 0e9.6) before surgery to 1.6 (range, 0e8; P ¼ .01) at final follow-up. The MEPS also improved significantly from a poor level, 57 (range, 10e85) before surgery to good, 88 (range, 50e100; P ¼ .01) at final follow-up. The final follow-up DASH score was 13 (range, 0e58). At final follow-up, the ASES pain score was 40 (range, 10e50), ASES function score was 44 (range, 6 to 50), ASES satisfaction score was 9 (range, 5e10), and the ASES composite score was 85 (range, 29e100). The final follow-up MEPS included 15 excellent (48%), 10 good (32%), 5 fair (16%), results and 1 poor (3%) result. These results are included in Table 2. No wound infections occurred, and there were no immediate postoperative or long-term neurovascular complications. One patient continued to be symptomatic and pursued an additional AOA and eventual open contracture release. Another patient experienced an unrelated ipsilateral septic elbow infection 7 months after his arthroscopic debridement that resolved with open debridement and intravenous antibiotics. Twelve patients noted some pain in terminal extension, and 2 patients had ongoing pain throughout their ROM. All elbows were noted to be stable on final examination. The correlation analysis revealed that the postoperative MEPS was lower in older patients (R ¼ 0.33; P ¼ .086), in patients with higher levels of postoperative pain (VAS) (R ¼ 0.47; P ¼ .012), and in patients with low postoperative DASH scores (R ¼ 0.65; P < .001). Higher scores on the postoperative MEPS were associated with improved ASES pain (R ¼ 0.72; P < .001), ASES function (R ¼ 0.57; P ¼ .002), and ASES combined scores (R ¼ 0.71; P < .001). Postoperative motion improvement did not correlate with postoperative pain levels (VAS) (R ¼ 0.02; P ¼ .92) or ASES function values (R ¼ 0.20; P ¼ .28). Higher preoperative VAS scores were correlated with better postoperative ASES satisfaction scores (R ¼ 0.45; P ¼ .012), suggesting that patients who experienced more pain before surgery were more satisfied with the procedure after surgery. No significant difference was found between patients who required cubital tunnel release compared with those who were not released. Multivariable linear regression analysis revealed a significant association between age and improvement Vol. 41, February 2016
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TABLE 1.
Patient
preoperative ROM (P ¼ .008), and prior surgery (P ¼ .008) influenced the final MEPS. Men had a higher final MEPS scores than women, and smokers had lower final MEPS than nonsmokers. Greater preoperative ROM was associated with better final MEPS. Any prior elbow surgery was associated with lower final MEPS.
ROM Results Before Surgery ( ; Range)
During Surgery ( ; Range)
After Surgery ( ; Range)
1
75 (40e115)
125 (15e140)
125 (15e140)
2
114 (22e136)
145 (0e145)
140 (3e143)
3
126 (10e136)
136 (0e136)
140 (0e140)
4
100 (35e135)
130 (5e135)
123 (12e135)
5
135 (10e145)
145 (0e145)
120 (15e135)
6
82 (38e120)
130 (0e130)
92 (28e120)
7
94 (40e134)
124 (10e134)
122 (28e150) 132 (0e132)
8
115 (5e120)
135 (0e135)
9
43 (45e88)
90 (0e90)
78 (32e110)
10
115 (15e130)
NA
120 (10e130)
11
90 (30e120)
130 (0e130)
123 (17e140)
12
100 (30e130)
145 (0e145)
120 (10e130)
13
92 (38e130)
125 (15e140)
103 (32e135)
14
112 (20e132)
140 (0e140)
120 (5e125)
15
100 (30e130)
140 (0e140)
125 (5e130)
16
85 (25e110)
140 (0e140)
128 (8e136)
17
105 (30e135)
NA
125 (20e145)
18
110 (20e130)
125 (10e135)
114 (12e126)
19
100 (25e125)
130 (5e135)
135 (5e140)
20
135 (5e140)
NA
135 (5e140)
21
104 (20e124)
135 (5e140)
140 (0e140)
22
100 (25e125)
145 (0e145)
150 (0e150)
23
110 (30e140)
140 (0e140)
128 (20e148)
24
94 (46e140)
145 (0e145)
107 (28e135)
25
135 (15e150)
145 (5e150)
131 (21e152)
26
110 (20e130)
135 (0e135)
138 (0e138)
27
126 (10e136)
130 (0e130)
145 (0e145)
28
102 (32e134)
145 (0e145)
150 (0e150)
29
95 (25e120)
140 (0e140)
120 (5e125)
30
44 (18e62)
110 (0e110)
80 (18e98)
31
86 (30e116)
145 (0e145)
120 (10e130)
NA, not available.
in ROM with surgery (P ¼ .04). Younger patients had more improvement in ROM than older individuals. Postoperative motion was associated with the method of capsular release (sharp > shaver) (P ¼ .01). Better preoperative motion was associated with more improvement in motion with surgery (P < .001). Sex, cubital tunnel release, tobacco use, diabetes mellitus, and BMI (P ¼ .053) were not found to have a statistically significant association with the final ROM. Multivariable linear regression analysis also revealed that sex (P ¼ .007), tobacco use (P ¼ .002), J Hand Surg Am.
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DISCUSSION Elbow osteoarthritis is a potential cause of pain and disability that predominantly affects men subjecting their upper extremities to high levels of force. The treatment of elbow osteoarthritis with open ulnohumeral arthroplasty techniques has been reported; however, AOA has not been as well documented nor widely adopted as a technique for treating symptomatic osteoarthritis of the elbow. Adams et al16 reported results similar to ours on 42 elbows after AOA with 81% of the patients achieving good to excellent results. Their patients also experienced improvement in mean flexion (14 ), extension (13 ), and pain, which were similar to our results. Krishnan et al15 and Savoie et al14 in separate reports achieved more improvement in motion than we found in our study; however, the loss of motion before surgery was more profound in their patients. Krishnan et al15 achieved a total arc improvement of 73 (60 before surgery to 133 after surgery), and Savoie et al14 reached 81 of improvement in composite motion. Our study did not find a similar degree of improvement in the full arc of motion, but our patients started with an average preoperative arc of motion of 102 . Those patients with a preoperative total arc of motion greater than 135 may be at risk of loss of motion with this procedure. We found that the average intraoperative ROM was greater than the average postoperative motion, which indicates that there is a tendency for elbow motion to revert to preoperative levels; however, when we analyzed patients individually, several gained motion at final follow-up when compared with their intraoperative measurement. This difference could have resulted from intraoperative goniometer measurement error and/or measurements that were underestimated owing to swelling from extravasation of fluid. Moreover, gains may have been made during the postoperative period owing to gradual stretching/ relaxation of contracted soft tissues. Soft tissue stretching may have been easier for patients after surgery owing to the lack of mechanical impingement from bone osteophytes as well as the reduction in pain. The results from our retrospective review reveal that elbow AOA is a safe procedure that can provide Vol. 41, February 2016
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TABLE 2.
Results Criteria
Before Surgery, Average (Range)
Extension ( ) Flexion ( )
ROM (flexion-extension arc) ( ) Pronation ( )
Supination ( ) MEPS VAS
After Surgery, Average (Range)
P
25 12 (0e46)
12 10 (0e32)
< .001
126 15 (62e150)
135 12 (98e152)
< .001
102 21 (43e135)
124 18 (78e150)
< .001
80 1 (75e80)
80 4 (60e90)
> .05
78 7 (50e80)
79 4 (60e80)
> .05
57 18 (10e85)
88 14 (50e100)
< .001
2 2 (0e8)
< .001
6 3 (0e9.6)
DASH
NA
13 18 (0e57.5)
ASES: pain
NA
40 12 (10e50)
NA, not available.
FIGURE 1: ROM change.
significant pain relief and improvement in ROM. Before surgery, VAS scores were higher in patients who also had low MEPS. This implies that those patients with increased pain also experienced more disability from the elbow. Long-term gains in ROM did not correlate with subjective pain or functional outcomes. In addition, preoperative VAS scores were positively correlated with ASES satisfaction scores. This suggests that patients who experienced more pain before surgery were more satisfied with the procedure after surgery. The benefits of elbow AOA J Hand Surg Am.
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include gains in ROM; yet, patient satisfaction seemed to correspond more with pain relief. Three patients presented with full ROM and either lost or did not gain motion with the procedure. They had improved pain levels at final follow-up and were satisfied with the results. Increasing age corresponded with less improvement in motion at final follow-up, lower postoperative MEPS, and higher DASH scores, implying that older patients did not reach the same degree of functional recovery as younger patients. Age, Vol. 41, February 2016
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however, did not seem to correlate with patient satisfaction with the procedure. This would suggest that older patients’ satisfaction did not seem to be dependent on, or negatively affected by, their lessor functional outcomes. In the multivariable analysis, sex, tobacco use, diabetes mellitus, and BMI did not influence the final ROM. Sex, tobacco use, preoperative ROM, and prior surgery influenced the final MEPS. One weakness of this study was that the technique for capsular release was not consistent. Initially, all anterior capsulotomies were performed with the arthroscopic shaver with great care to preserve the overlying neurovascular structures. With greater experience, this was completed with an arthroscopic biter, allowing a more controlled and precise release. Because our data showed that patients with a sharp release had more improvement in ROM, this could have influenced the outcome of patients treated earlier in the series compared with those who were treated later. In addition, some of the open ulnar nerve transposition cases included a release of the posterior aspect of the medial collateral ligament. The operative notes did not consistently report this and, therefore, was not analyzed in the data set. Another weakness was the inability to verify compliance with therapy. The postoperative therapy regimen was standardized, and patients started motion at the same interval after surgery, but we had no way to monitor patient effort, total daily exercise, or compliance with night orthosis wear or static progressive orthosis wear. The decision for the use of a static progressive orthosis was also subjective and may have influenced the results more favorably for those who had the opportunity to use it. The degree of arthritic change was recorded but not specifically analyzed in relation to outcome and was a confounder that could have influenced the results of this technique. Another weakness was that the number of patients in the subgroup analysis was limited. There were very few female patients (n ¼ 4), tobacco users (n ¼ 5), and those with prior surgery (n ¼ 7). The results should be interpreted with caution because the small numbers available for analysis may result in type 2 error. As with all retrospective studies, there may be other unknown systematic effects that may be comingled or confounded with the study effects and may tend to bias the results. At the conclusion of the study, 37% of patients continued to have some pain, suggesting that elbow AOA is a somewhat unreliable provider of complete pain relief. However, 22 of the 31 patients reported a 9 or higher on a 10-point satisfaction rating for the J Hand Surg Am.
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procedure, implying that pain relief for the majority of patients undergoing elbow AOA was enough to allow pursuit of their daily activities to a satisfactory level. As the technique evolves, elbow AOA will continue to be a technically demanding procedure yet it can be used safely and reliably to provide significant pain relief and a high level of patient satisfaction. ACKNOWLEDGMENTS N.G.H. received support from Kaiser Foundation Health Plan. REFERENCES 1. Huskisson EC, Dieppe PA, Tucker AK, Cannell LB. Another look at osteoarthritis. An Rhum Dis. 1979;38(5):423e428. 2. Stanley D. Prevalence and etiology of symptomatic elbow osteoarthritis. J Shoulder Elbow Surg. 1994;3(6):386e389. 3. Elfeddali R, Schreuder MHE, Eygendaal D. Arthroscopic elbow surgery, is it safe? J Shoulder Elbow Surg. 2013;22(5):647e652. 4. Morrey BF. Primary degenerative arthritis of the elbow. Treatment by ulnohumeral arthroplasty. J Bone Joint Surg Br. 1992;74(3): 409e413. 5. Leber C, Melone CP. Total elbow replacement. Orthop Rev. 1988;17(9):857e863. 6. Espag MP, Back DL, Clark DI, Lunn PG. Early results of the SouterStrathclyde unlinked total elbow arthroplasty in patients with osteoarthritis. J Bone Joint Surg Br. 2003;85(3):351e353. 7. Kozak TK, Adams RA, Morrey BF. Total elbow arthroplasty in primary osteoarthritis of the elbow. J Arthroplasty. 1998;13(7): 1630e1635. 8. Inglis AE, Pellicci PM. Total elbow replacement. J Bone Joint Surg Am. 1980;62(8):1252e1258. 9. Wada T, Isogai S, Ishii S, Yamashita T. Debridement arthroplasty for primary osteoarthritis of the elbow. J Bone Joint Surg Am. 2004;86(2): 233e241. 10. Phillips NJ, Ali A, Stanley D. Treatment of primary degenerative arthritis of the elbow by ulnohumeral arthroplasty. A long-term followup. J Bone Joint Surg Br. 2003;85(3):347e350. 11. Antuna SA, Morrey BF, Adams RA, O’Driscoll SW. Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: long-term outcome and complications. J Bone Joint Surg Am. 2002;84(12): 2168e2173. 12. Oka Y, Ohta K, Saitoh I. Debridement arthroplasty for osteoarthritis of the elbow. Clin Orthop Relat Res. 1998;351:127e134. 13. Mansat P, Morrey BF. The “column procedure” a limited surgical approach for the treatment of stiff elbows. J Bone Joint Surg Am. 1998;80(11):1603e1615. 14. Savoie FH III, Nunley PD, Field LD. Arthroscopic management of the arthritic elbow: indications, technique, and results. J Shoulder Elbow Surg. 1999;8(3):214e219. 15. Krishnan SG, Harkins DC, Pennington SD, Harrison DK, Burkhead WZ. Arthroscopic ulnohumeral arthroplasty for degenerative arthritis of the elbow in patients under fifty years. J Shoulder Elbow Surg. 2007;16(4):443e448. 16. Adams JE, Wolff LH III, Merten SM, Steinmann SP. Osteoarthritis of the elbow: results of arthroscopic osteophyte resection and capsulectomy. J Shoulder Elbow Surg. 2008;17(1):126e131. 17. Aitken RC. Measurement of feelings using visual analog scales. Proc R Soc Med. 1969;62(10):989e993. 18. Dawson J, Fitzpatrick R, Carr A, Murray D. Questionnaire on the perceptions of patients about total hip replacement. J Bone Joint Surg Br. 1996;78(2):185e190.
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19. Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am. 1986;68(5): 669e674. 20. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder, and Hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29(6):602e608. 21. King GJW, Richards RR, Zuckerman JD, et al. A standardized method for assessment of elbow function. Research Committee, American Shoulder and elbow Surgeons. J Shoulder Elbow Surg. 1999;8(4):351e354.
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22. Michener LA, McClure PW, Sennett BJ. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg. 2002;11(6):587e594. 23. John M, Angst F, Awiszus F, King GJW, MacDermid JC, Simmen BR. The American Shoulder and Elbow Surgeons Elbow Questionnaire: cross-cultural adaptation into German and evaluation of its psychometric properties. J Hand Ther. 2010;23(3):301e314. 24. Blonna D, Lee GC, O’Driscoll SW. Arthroscopic restoration of terminal elbow extension in high-level athletes. Am J Sports Med. 2010;38(12):2509e2515.
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Outcomes of Elbow Arthroscopic Osteocapsular Arthroplasty Samuel E. Galle, MD,* John D. Beck, MD,† Raoul J. Burchette, MA, MS,‡ Neil G. Harness, MD§
Purpose To evaluate the results of elbow arthroscopic osteocapsular arthroplasty (AOA) and determine which factors influence the outcome in a large group of patients with primary osteoarthritis. Methods A consecutive series of 46 patients with elbow osteoarthritis underwent AOA by a single surgeon (N.G.H.) between December 2005 and January 2013. Thirty-one patients returned for a comprehensive physical examination an average of 3.4 years later. The outcomes measures included visual analog scale (VAS), Mayo Elbow Performance Scores (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH), and American Shoulder and Elbow Society (ASES) scores. Preoperative and postoperative continuous variables were compared and a multivariable regression analysis was performed. Results Thirty-one patients with a mean age of 48 years (range, 19e77 years) returned for final follow-up, including 27 men and 4 women. Statistically significant improvement was observed in extension deficit (24 before surgery to 12 after surgery), flexion (126 before surgery to 135 after surgery), visual analog scale (6.4 before surgery to 1.6 after surgery), and Mayo Elbow Performance Scores (57 [poor] before surgery to 88 [good] after surgery). Subjective scores included a mean postoperative Disabilities of the Arm, Shoulder, and Hand score of 13 and an American Shoulder and Elbow Society pain score of 40. No complications were noted at final follow-up. Conclusions Elbow AOA is a safe, efficacious treatment for patients with mild to moderate osteoarthritis. Our retrospective review found significant improvement in elbow motion, pain and clinical outcomes. (J Hand Surg Am. 2016;41(2):184e191. Copyright Ó 2016 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Arthroscopy, contracture, elbow, osteoarthritis.
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osteoarthritis affects up to 2% of the population and is 4 times more common in men than women.1,2 Stanley2 noted in his review of 1,000 consecutive patients an overall YMPTOMATIC PRIMARY ELBOW
From the *Department of Orthopaedic Surgery, University of California, Irvine Health, Irvine, CA; the †Proliance Hand, Wrist, and Elbow Physicians, Kirkland, WA; the ‡Southern California Permanente Medical Group, Pasadena; and the §Kaiser Permanente Orange County, Anaheim, CA. Received for publication April 30, 2015; accepted in revised form November 18, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Neil G. Harness, MD, Kaiser Permanente Orange County, Kraemer Medical Office 1, 3460 E. La Palma Ave., Anaheim, CA 92806; e-mail: [email protected]. 0363-5023/16/4102-0003$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.11.018
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prevalence of symptomatic elbow osteoarthritis in men over the age of 40 years of 3.5%. Individuals between 30 and 50 years old engaged in heavy manual labor are most affected.2e4 Common presentations include a loss of terminal extension and/or development of pain leading to functional limitations in activities of daily living. Conservative treatments commonly fail to relieve symptoms, and although total elbow arthroplasty is reliable in the management of moderate to severe rheumatoid arthritis and some cases of osteoarthritis, implant durability is limited and recipients must refrain from heavy lifting.5e8 This has led surgeons to seek alternative treatment options for those that fail nonsurgical management.
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Ulnohumeral or osteocapsular arthroplasty combines capsular release, synovectomy, osteophyte/loose body removal, and contouring of the humerus and ulna to reduce impingement and improve motion. Several studies have demonstrated that open ulnohumeral arthroplasty reliably relieves pain in the majority of patients.9e13 With the advancement of surgical equipment and techniques, arthroscopic osteocapsular arthroplasty (AOA) has become an option for patients with functionally limiting osteoarthritis of the elbow. This technique has the potential for less soft tissue trauma, allows for complete joint evaluation, and has been proven safe3; however, the number of reports on this surgical approach is limited. Savoie et al14 showed that arthroscopic ulnohumeral arthroplasty provided satisfactory results in 24 patients evaluated at an average of 32 months with a mean increase of 81 in arc of motion and a decrease in visual analog scale (VAS) pain score of 6.6. Krishnan et al15 reported on 11 patients who underwent arthroscopic ulnohumeral arthroplasty with an average of 26 months follow-up and found improvements in total range of motion (ROM), 73 , and pain, from 9.2 to 1.7 on a 10-point scale, where 10 is the worst pain. Adams et al16 reported on the results of 42 elbows after AOA and at a minimum of 2 years follow-up; 81% of patients noted good to excellent results. Elbow AOA has proven to be a safe and reliable procedure with the potential for improvement in function and pain. However, reports are limited, and the technique has not gained wide popularity owing to the challenging nature of the surgery, potential for serious complications, and small number of patients who present with primary elbow osteoarthritis. The degree of improvement in motion and pain varies widely between primary reports. Moreover, it is not clear which preoperative factors predict a favorable outcome following surgery. The objective of this study was to evaluate the results of elbow AOA and determine which factors influence the outcome in a large group of patients with primary osteoarthritis. MATERIALS AND METHODS After institutional review board approval was obtained, we conducted a retrospective cohort study of all patients at least 18 years of age who underwent elbow AOA at Kaiser Permanente Southern California from August 2005 to December 2013. A total of 46 patients were identified who underwent AOA by a single surgeon for symptomatic, mild to moderate, primary degenerative osteoarthritis of the elbow. J Hand Surg Am.
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During the course of the study, 2 patients died; 4 were no longer members of Kaiser Permanente, which precluded inclusion in the study based on institutional review board rules; 2 declined to participate; and 7 patients were lost to follow-up. This left 31 patients for final analysis. We included patients with symptomatic mild to moderate elbow osteoarthritis with or without loss of elbow motion. Exclusion criteria included inflammatory arthritides, arthritis related to osteochondritis dissecans, elbow instability, prior elbow fracture, prior anterior ulnar nerve transposition, and severe medical comorbidities precluding surgery. Data collection The preoperative evaluation was performed by the senior author (N.G.H.), which included a complete history and physical examination. Range of motion measurements were recorded for flexion, extension, supination, and pronation using a hand-held goniometer. Pain was quantitated using a VAS both before and after surgery.17 Pre- and postoperative function was determined using the Mayo Elbow Performance Scores (MEPS).18 Intraoperative elbow flexion and extension was measured at the completion of the procedure using a hand-held goniometer and reported with pre- and postoperative values for comparison. Patient charts were retrospectively reviewed to determine: age, sex, hand dominance, side of operation, tobacco use, workers’ compensation status, occupation, chief complaint, underlying diagnosis for elbow contracture, prior elbow surgery, ulnar neuritis, relation of pain to ROM, and medical comorbidities, including diabetes mellitus and body mass index (BMI). Radiographic evaluation was performed at the time of the initial evaluation, and arthritis was retrospectively graded according the Broberg-Morrey radiographic staging system.19 Patients included in the study were invited to return for a final evaluation performed by a resident (S.E.G.) or attending surgeon (N.G.H.) in a nonblinded fashion. The assessment included elbow appearance (scarring, areas of tenderness, portal complications), ulnar nerve irritability/subluxation, ROM, elbow stability, strength (biceps/triceps/extensor pollicis longus/flexor pollicis longus/first dorsal interroseous; grip; pinch), pain with ROM (midrange vs end range), sensibility, and vascular status (pulse: radial and ulnar). Stability was determined using varus/valgus laxity at 30 of flexion compared with the contralateral limb. Grip and pinch strengths were assessed using a Jamar grip tester, and results were averaged from 3 attempts. Motor strength was evaluated using standard manual motor testing by the examiner. Sensibility was Vol. 41, February 2016
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determined by 2-point discrimination with normal defined as 5 mm or less. Subjective pain was determined using VAS and American Shoulder and Elbow Society (ASES) pain scales. Subjective postoperative outcome of functional ability was evaluted using the Disability of the Arm, Shoulder, and Hand (DASH)20 and the ASES21,22 scores. American Shoulder and Elbow Society scores for both function and pain were analyzed independently and combined as discussed by John et al.23 Final outcome was determined using MEPS scoring classifications: excellent, greater than 89; good, 75 to 89; fair, 60 to 74; and poor, less than 60. All postoperative complications were noted, detailing ongoing symptoms. Surgical technique The operative technique for AOA was performed by N.G.H in all cases in a similar manner to that described by Blonna et al.24 After general endotracheal anesthesia, the patients were rotated into a prone position. A 4-portal (proximal anteromedial, anterolateral, direct posterior, and posterolateral) technique was used for complete elbow arthroscopic evaluation and treatment. Accessory portals were used for placement of arthroscopic retractors as necessary. In the anterior compartment, all osteophytes and loose bodies were removed. An anterior capsulotomy was performed in all cases. As with Blonna et al,24 the capsulotomy technique evolved during the course of the senior surgeon’s experience with the technique. Initially, this was achieved with an arthroscopic shaver and subsequently with an arthroscopic biter. A full capsulectomy was never performed. A direct posterior portal was then created along with a posterolateral portal. Osteophytes were removed from the olecranon fossa and tip of the olecranon. Both the posteromedial and the posterolateral gutters were also cleared of any loose bodies. Satisfactory olecranon bone excision was determined when the articular cartilage of the trochlea was visualized easily with the elbow in 45 of flexion. A posterior capsulotomy was performed in cases in which flexion could not be restored by anterior osteophyte excision alone. In cases requiring more extensive medial dissection and capsulotomy, an open approach was used to identify the ulnar nerve and protect it. In cases in which preoperative elbow flexion was less than 90 , the ulnar nerve was transposed through an open approach at the time of arthroscopy. In some of the ulnar nerve transposition cases, the posterior fibers of the medial collateral ligament were divided under direct visualization to improve elbow flexion. This was not consistently reported in the operative reports and was not included in the data analysis. J Hand Surg Am.
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Postoperative care All patients were placed in a soft dressing, and immediate motion was encouraged. Formal physical therapy began between 7 to 10 days after surgery and consisted of ROM exercises and nighttime extension splinting with a custom fabricated thermoplastic orthosis. If patients were unable to maintain motion or were not progressing appropriately by 6 weeks after surgery, they used a static progressive orthosis. (Joint Active Systems, Effingham, IL). The clinical criteria for incorporation of a static progressive orthosis in the rehabilitation regimen were not standardized, and 8 patients used the device during the study period. Static progressive orthosis fabrication was not analyzed as a factor in the surgical outcome. Continuous passive motion was not used by any of the patients. Statistical analysis Descriptive statistics were computed for pre- and postsurgical measures and of the changes from pre- to postoperative values. Relationships between categorical variables such as sex, hand dominance, and operative side were examined using chi-square tests. Paired t tests and Wilcoxon signed rank test were used to look for statistically significant changes from before to after surgery as well as before surgery to follow-up after surgery including at least 7 months of follow-up. We also used Pearson and Spearman correlations to examine change by sequence number to determine if there was evidence to suggest that procedural changes over time made any difference in the measured outcomes. Independent groups t tests and Wilcoxon rank sum tests were used to compare measured variables and changes in measured variables by specific procedural techniques (sharp vs shaver). All demographic, preoperative, and postoperative subjective/objective measures were evaluated for correlations to elucidate critical factors in the success of elbow AOA. Multivariable analysis Age, sex, diabetes status, smoker status, BMI, preoperative ROM, the number of prior surgeries, cubital tunnel release status, and the surgical technique (none, sharp/biter, or shaver) were included as candidate explanatory covariates for the long-term ROM outcome and MEPS. Pearson and Spearman correlations were used among the independent variables to check for possible dependencies and as a factor analysis with a varimax rotation requiring the eigenvalues to be greater than 0.8. Variables that loaded on the same rotated factors with weights greater than 0.4 were Vol. 41, February 2016
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further checked for explicit association by both the Pearson chi-square and the Fisher exact test for discrete values and analysis of variance and by the KruskalWallis test if one was continuous and one was discrete. The Pearson and Spearman correlations were used when both were continuous. Any significant associations were examined as interaction terms in the linear regression model. Furthermore, a best subsets selection process (maximizing R2 and also maximizing the adjusted R2) was used and the results were compared with a backward elimination of variables down to P < 0.15. RESULTS The final follow-up group of 31 patients consisted of 27 men and 4 women with an average age of 48 years (range, 19e77 years). Occupations included 21 sedentary jobs and 10 heavy manual activity jobs. The youngest patient was 19 years old and presented with osteoarthritis, which was related to an elbow dislocation as a child. There were 6 patients with type II diabetes mellitus, 5 patients that were using tobacco at the time of the operation, and none with a prior diagnosis of inflammatory arthropathy. The vast majority of patients were right-handed (97%), and the right side was the operative side in 84% of cases. Twenty-four patients had no prior surgery on the ipsilateral upper extremity, and 7 had various prior procedures including 1 prior elbow contracture release. Broberg-Morrey radiographic staging revealed 8 patients with grade 1, 21 with grade 2, and 2 with grade 3 osteoarthritis prior to surgical intervention. Follow-up averaged 41 months (range, 7e98 months). All patients had been treated with some form of conservative therapy including but not limited to nonsteroidal anti-inflammatories, physical therapy, and corticosteroid injections prior to surgery. The average total preoperative arc of motion was 102 (range, 43 e135 ) with an average flexion of 126 (range, 62 e150 ) and extension of 24 (range, 0 e46 ). All but 3 patients presented with limitation of ROM and pain. These 3 patients had a functional ROM, and their primary complaint was pain due to impingement. The average total intraoperative arc of motion was 133 (range, 90 e145 ) with an average flexion of 136 (range, 90 e150 ) and extension of 3 (range, 0 e15 ) (Table 1). After surgery, the average total arc of motion was 124 (range, 78 e150 ; P < .01) with an average flexion of 135 (range, 98 e152 ; P < .01) and extension of 12 (range, 0 e32 ; P < .01) (Table 2). The improvement in motion in each patient is represented in Figure 1. J Hand Surg Am.
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Patients 29 and 30 had small losses of motion, and patient 31 had no improvement in motion. Before surgery, all but 3 patients had pain as their main functional limitation with 23 patients having terminal extension pain, 4 with midarc pain, and 1 with pain throughout the ROM. Final average scores were reported and include the following. The VAS improved significantly from 6.4 (range, 0e9.6) before surgery to 1.6 (range, 0e8; P ¼ .01) at final follow-up. The MEPS also improved significantly from a poor level, 57 (range, 10e85) before surgery to good, 88 (range, 50e100; P ¼ .01) at final follow-up. The final follow-up DASH score was 13 (range, 0e58). At final follow-up, the ASES pain score was 40 (range, 10e50), ASES function score was 44 (range, 6 to 50), ASES satisfaction score was 9 (range, 5e10), and the ASES composite score was 85 (range, 29e100). The final follow-up MEPS included 15 excellent (48%), 10 good (32%), 5 fair (16%), results and 1 poor (3%) result. These results are included in Table 2. No wound infections occurred, and there were no immediate postoperative or long-term neurovascular complications. One patient continued to be symptomatic and pursued an additional AOA and eventual open contracture release. Another patient experienced an unrelated ipsilateral septic elbow infection 7 months after his arthroscopic debridement that resolved with open debridement and intravenous antibiotics. Twelve patients noted some pain in terminal extension, and 2 patients had ongoing pain throughout their ROM. All elbows were noted to be stable on final examination. The correlation analysis revealed that the postoperative MEPS was lower in older patients (R ¼ 0.33; P ¼ .086), in patients with higher levels of postoperative pain (VAS) (R ¼ 0.47; P ¼ .012), and in patients with low postoperative DASH scores (R ¼ 0.65; P < .001). Higher scores on the postoperative MEPS were associated with improved ASES pain (R ¼ 0.72; P < .001), ASES function (R ¼ 0.57; P ¼ .002), and ASES combined scores (R ¼ 0.71; P < .001). Postoperative motion improvement did not correlate with postoperative pain levels (VAS) (R ¼ 0.02; P ¼ .92) or ASES function values (R ¼ 0.20; P ¼ .28). Higher preoperative VAS scores were correlated with better postoperative ASES satisfaction scores (R ¼ 0.45; P ¼ .012), suggesting that patients who experienced more pain before surgery were more satisfied with the procedure after surgery. No significant difference was found between patients who required cubital tunnel release compared with those who were not released. Multivariable linear regression analysis revealed a significant association between age and improvement Vol. 41, February 2016
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TABLE 1.
Patient
preoperative ROM (P ¼ .008), and prior surgery (P ¼ .008) influenced the final MEPS. Men had a higher final MEPS scores than women, and smokers had lower final MEPS than nonsmokers. Greater preoperative ROM was associated with better final MEPS. Any prior elbow surgery was associated with lower final MEPS.
ROM Results Before Surgery ( ; Range)
During Surgery ( ; Range)
After Surgery ( ; Range)
1
75 (40e115)
125 (15e140)
125 (15e140)
2
114 (22e136)
145 (0e145)
140 (3e143)
3
126 (10e136)
136 (0e136)
140 (0e140)
4
100 (35e135)
130 (5e135)
123 (12e135)
5
135 (10e145)
145 (0e145)
120 (15e135)
6
82 (38e120)
130 (0e130)
92 (28e120)
7
94 (40e134)
124 (10e134)
122 (28e150) 132 (0e132)
8
115 (5e120)
135 (0e135)
9
43 (45e88)
90 (0e90)
78 (32e110)
10
115 (15e130)
NA
120 (10e130)
11
90 (30e120)
130 (0e130)
123 (17e140)
12
100 (30e130)
145 (0e145)
120 (10e130)
13
92 (38e130)
125 (15e140)
103 (32e135)
14
112 (20e132)
140 (0e140)
120 (5e125)
15
100 (30e130)
140 (0e140)
125 (5e130)
16
85 (25e110)
140 (0e140)
128 (8e136)
17
105 (30e135)
NA
125 (20e145)
18
110 (20e130)
125 (10e135)
114 (12e126)
19
100 (25e125)
130 (5e135)
135 (5e140)
20
135 (5e140)
NA
135 (5e140)
21
104 (20e124)
135 (5e140)
140 (0e140)
22
100 (25e125)
145 (0e145)
150 (0e150)
23
110 (30e140)
140 (0e140)
128 (20e148)
24
94 (46e140)
145 (0e145)
107 (28e135)
25
135 (15e150)
145 (5e150)
131 (21e152)
26
110 (20e130)
135 (0e135)
138 (0e138)
27
126 (10e136)
130 (0e130)
145 (0e145)
28
102 (32e134)
145 (0e145)
150 (0e150)
29
95 (25e120)
140 (0e140)
120 (5e125)
30
44 (18e62)
110 (0e110)
80 (18e98)
31
86 (30e116)
145 (0e145)
120 (10e130)
NA, not available.
in ROM with surgery (P ¼ .04). Younger patients had more improvement in ROM than older individuals. Postoperative motion was associated with the method of capsular release (sharp > shaver) (P ¼ .01). Better preoperative motion was associated with more improvement in motion with surgery (P < .001). Sex, cubital tunnel release, tobacco use, diabetes mellitus, and BMI (P ¼ .053) were not found to have a statistically significant association with the final ROM. Multivariable linear regression analysis also revealed that sex (P ¼ .007), tobacco use (P ¼ .002), J Hand Surg Am.
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DISCUSSION Elbow osteoarthritis is a potential cause of pain and disability that predominantly affects men subjecting their upper extremities to high levels of force. The treatment of elbow osteoarthritis with open ulnohumeral arthroplasty techniques has been reported; however, AOA has not been as well documented nor widely adopted as a technique for treating symptomatic osteoarthritis of the elbow. Adams et al16 reported results similar to ours on 42 elbows after AOA with 81% of the patients achieving good to excellent results. Their patients also experienced improvement in mean flexion (14 ), extension (13 ), and pain, which were similar to our results. Krishnan et al15 and Savoie et al14 in separate reports achieved more improvement in motion than we found in our study; however, the loss of motion before surgery was more profound in their patients. Krishnan et al15 achieved a total arc improvement of 73 (60 before surgery to 133 after surgery), and Savoie et al14 reached 81 of improvement in composite motion. Our study did not find a similar degree of improvement in the full arc of motion, but our patients started with an average preoperative arc of motion of 102 . Those patients with a preoperative total arc of motion greater than 135 may be at risk of loss of motion with this procedure. We found that the average intraoperative ROM was greater than the average postoperative motion, which indicates that there is a tendency for elbow motion to revert to preoperative levels; however, when we analyzed patients individually, several gained motion at final follow-up when compared with their intraoperative measurement. This difference could have resulted from intraoperative goniometer measurement error and/or measurements that were underestimated owing to swelling from extravasation of fluid. Moreover, gains may have been made during the postoperative period owing to gradual stretching/ relaxation of contracted soft tissues. Soft tissue stretching may have been easier for patients after surgery owing to the lack of mechanical impingement from bone osteophytes as well as the reduction in pain. The results from our retrospective review reveal that elbow AOA is a safe procedure that can provide Vol. 41, February 2016
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TABLE 2.
Results Criteria
Before Surgery, Average (Range)
Extension ( ) Flexion ( )
ROM (flexion-extension arc) ( ) Pronation ( )
Supination ( ) MEPS VAS
After Surgery, Average (Range)
P
25 12 (0e46)
12 10 (0e32)
< .001
126 15 (62e150)
135 12 (98e152)
< .001
102 21 (43e135)
124 18 (78e150)
< .001
80 1 (75e80)
80 4 (60e90)
> .05
78 7 (50e80)
79 4 (60e80)
> .05
57 18 (10e85)
88 14 (50e100)
< .001
2 2 (0e8)
< .001
6 3 (0e9.6)
DASH
NA
13 18 (0e57.5)
ASES: pain
NA
40 12 (10e50)
NA, not available.
FIGURE 1: ROM change.
significant pain relief and improvement in ROM. Before surgery, VAS scores were higher in patients who also had low MEPS. This implies that those patients with increased pain also experienced more disability from the elbow. Long-term gains in ROM did not correlate with subjective pain or functional outcomes. In addition, preoperative VAS scores were positively correlated with ASES satisfaction scores. This suggests that patients who experienced more pain before surgery were more satisfied with the procedure after surgery. The benefits of elbow AOA J Hand Surg Am.
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include gains in ROM; yet, patient satisfaction seemed to correspond more with pain relief. Three patients presented with full ROM and either lost or did not gain motion with the procedure. They had improved pain levels at final follow-up and were satisfied with the results. Increasing age corresponded with less improvement in motion at final follow-up, lower postoperative MEPS, and higher DASH scores, implying that older patients did not reach the same degree of functional recovery as younger patients. Age, Vol. 41, February 2016
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however, did not seem to correlate with patient satisfaction with the procedure. This would suggest that older patients’ satisfaction did not seem to be dependent on, or negatively affected by, their lessor functional outcomes. In the multivariable analysis, sex, tobacco use, diabetes mellitus, and BMI did not influence the final ROM. Sex, tobacco use, preoperative ROM, and prior surgery influenced the final MEPS. One weakness of this study was that the technique for capsular release was not consistent. Initially, all anterior capsulotomies were performed with the arthroscopic shaver with great care to preserve the overlying neurovascular structures. With greater experience, this was completed with an arthroscopic biter, allowing a more controlled and precise release. Because our data showed that patients with a sharp release had more improvement in ROM, this could have influenced the outcome of patients treated earlier in the series compared with those who were treated later. In addition, some of the open ulnar nerve transposition cases included a release of the posterior aspect of the medial collateral ligament. The operative notes did not consistently report this and, therefore, was not analyzed in the data set. Another weakness was the inability to verify compliance with therapy. The postoperative therapy regimen was standardized, and patients started motion at the same interval after surgery, but we had no way to monitor patient effort, total daily exercise, or compliance with night orthosis wear or static progressive orthosis wear. The decision for the use of a static progressive orthosis was also subjective and may have influenced the results more favorably for those who had the opportunity to use it. The degree of arthritic change was recorded but not specifically analyzed in relation to outcome and was a confounder that could have influenced the results of this technique. Another weakness was that the number of patients in the subgroup analysis was limited. There were very few female patients (n ¼ 4), tobacco users (n ¼ 5), and those with prior surgery (n ¼ 7). The results should be interpreted with caution because the small numbers available for analysis may result in type 2 error. As with all retrospective studies, there may be other unknown systematic effects that may be comingled or confounded with the study effects and may tend to bias the results. At the conclusion of the study, 37% of patients continued to have some pain, suggesting that elbow AOA is a somewhat unreliable provider of complete pain relief. However, 22 of the 31 patients reported a 9 or higher on a 10-point satisfaction rating for the J Hand Surg Am.
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procedure, implying that pain relief for the majority of patients undergoing elbow AOA was enough to allow pursuit of their daily activities to a satisfactory level. As the technique evolves, elbow AOA will continue to be a technically demanding procedure yet it can be used safely and reliably to provide significant pain relief and a high level of patient satisfaction. ACKNOWLEDGMENTS N.G.H. received support from Kaiser Foundation Health Plan. REFERENCES 1. Huskisson EC, Dieppe PA, Tucker AK, Cannell LB. Another look at osteoarthritis. An Rhum Dis. 1979;38(5):423e428. 2. Stanley D. Prevalence and etiology of symptomatic elbow osteoarthritis. J Shoulder Elbow Surg. 1994;3(6):386e389. 3. Elfeddali R, Schreuder MHE, Eygendaal D. Arthroscopic elbow surgery, is it safe? J Shoulder Elbow Surg. 2013;22(5):647e652. 4. Morrey BF. Primary degenerative arthritis of the elbow. Treatment by ulnohumeral arthroplasty. J Bone Joint Surg Br. 1992;74(3): 409e413. 5. Leber C, Melone CP. Total elbow replacement. Orthop Rev. 1988;17(9):857e863. 6. Espag MP, Back DL, Clark DI, Lunn PG. Early results of the SouterStrathclyde unlinked total elbow arthroplasty in patients with osteoarthritis. J Bone Joint Surg Br. 2003;85(3):351e353. 7. Kozak TK, Adams RA, Morrey BF. Total elbow arthroplasty in primary osteoarthritis of the elbow. J Arthroplasty. 1998;13(7): 1630e1635. 8. Inglis AE, Pellicci PM. Total elbow replacement. J Bone Joint Surg Am. 1980;62(8):1252e1258. 9. Wada T, Isogai S, Ishii S, Yamashita T. Debridement arthroplasty for primary osteoarthritis of the elbow. J Bone Joint Surg Am. 2004;86(2): 233e241. 10. Phillips NJ, Ali A, Stanley D. Treatment of primary degenerative arthritis of the elbow by ulnohumeral arthroplasty. A long-term followup. J Bone Joint Surg Br. 2003;85(3):347e350. 11. Antuna SA, Morrey BF, Adams RA, O’Driscoll SW. Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: long-term outcome and complications. J Bone Joint Surg Am. 2002;84(12): 2168e2173. 12. Oka Y, Ohta K, Saitoh I. Debridement arthroplasty for osteoarthritis of the elbow. Clin Orthop Relat Res. 1998;351:127e134. 13. Mansat P, Morrey BF. The “column procedure” a limited surgical approach for the treatment of stiff elbows. J Bone Joint Surg Am. 1998;80(11):1603e1615. 14. Savoie FH III, Nunley PD, Field LD. Arthroscopic management of the arthritic elbow: indications, technique, and results. J Shoulder Elbow Surg. 1999;8(3):214e219. 15. Krishnan SG, Harkins DC, Pennington SD, Harrison DK, Burkhead WZ. Arthroscopic ulnohumeral arthroplasty for degenerative arthritis of the elbow in patients under fifty years. J Shoulder Elbow Surg. 2007;16(4):443e448. 16. Adams JE, Wolff LH III, Merten SM, Steinmann SP. Osteoarthritis of the elbow: results of arthroscopic osteophyte resection and capsulectomy. J Shoulder Elbow Surg. 2008;17(1):126e131. 17. Aitken RC. Measurement of feelings using visual analog scales. Proc R Soc Med. 1969;62(10):989e993. 18. Dawson J, Fitzpatrick R, Carr A, Murray D. Questionnaire on the perceptions of patients about total hip replacement. J Bone Joint Surg Br. 1996;78(2):185e190.
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19. Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am. 1986;68(5): 669e674. 20. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder, and Hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29(6):602e608. 21. King GJW, Richards RR, Zuckerman JD, et al. A standardized method for assessment of elbow function. Research Committee, American Shoulder and elbow Surgeons. J Shoulder Elbow Surg. 1999;8(4):351e354.
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22. Michener LA, McClure PW, Sennett BJ. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg. 2002;11(6):587e594. 23. John M, Angst F, Awiszus F, King GJW, MacDermid JC, Simmen BR. The American Shoulder and Elbow Surgeons Elbow Questionnaire: cross-cultural adaptation into German and evaluation of its psychometric properties. J Hand Ther. 2010;23(3):301e314. 24. Blonna D, Lee GC, O’Driscoll SW. Arthroscopic restoration of terminal elbow extension in high-level athletes. Am J Sports Med. 2010;38(12):2509e2515.
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