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Shoulder& Elbow. ISSN 1758-5732

E R E V I E W A R T I C L E

Primary elbow osteoarthritis: an updated reviewDeepthi Nandan Adla & David Stanley

Department of Orthopaedics, Northern General Hospital, Sheffield, UKDepartment of Orthopaedics, STH Foundation Trust, Sheffield, UK

Received

Received 30 April 2010;

accepted 16 July 2010

KeywordsPrimary osteoarthritis, elbow, aetiology, natural

history, management, open surgery and

arthroscopy, arthroplasty

Conflicts of Interest

None declared

Correspondence

David Stanley, Department of Orthopaedics,

Northern General Hospital, Sheffield, South

Yorkshire, S5 7AU, UK.

Tel.:+44 (0)114 2714025.Fax:+44 (0)114 2266796.

E-mail: [email protected]

DOI:10.1111/j.1758-5740.2010.00089.x

ABSTRACT

Primary elbow arthritis predominantly affects middle aged men undertaking heavy manual work. Patients

present with pain and limited movement butmay also complain of ulnar nerve sensory or motor symptoms.

Radiographic features include osteophytes at the tip of the olecranon and coronoid processes, loose bodies,

narrowing of the radiocapitellar joint space and thickening of the olecranon fossa membrane.

Treatment options range from conservative management using oral analgaesics and non-steroidal anti-

inflammatory drugs through to open debridement procedures, arthroscopy and occasionaly in selected

patients total elbow arthroplasty.

INTRODUCTION

Primary osteoarthritis (OA) of the elbow is a relatively uncommon

condition mainly affecting middle aged men. It accounts for 1% to

2% of patients presenting with all types of elbow arthritis [1]. In a

specialistrheumatologypractice,DohertyandPrestonidentified16

patients (7%)withelbow osteoarthritis from225 referrals withnon-nodal large joint osteoarthritis [2]. Previous reports on elbow OA

have notcommented on associated involvement at other sites but,

in this series, 71% of men had associated metacarpophalangeal

joint OA. As with the elbow, the metacarpophalangeal joint is

often considered an uncommon site for OA. It has been suggested

that this association occurs principally in those undertaking heavy

manual work (Missouri metacarpal syndrome) [2,3]. In a study

assessing 1000 consecutive fracture clinic patients, the prevalence

of symptomatic elbow osteoarthritis was noted to be 2%. The

condition was rarely seen in patients below 40 years of age and

was very uncommon in women [4].

AETIOLOGY

The aetiology of primary elbow OA is still unclear, although

combinations of environmental and genetic factors have been

implicated. In particular, there are a number of studies that have

suggested heavy and repetitive work to be important factors.

Elbow osteoarthritis was noted in 32.8% of 744 German coal

miners who used pneumatic boring hammers on a regular

basis [5]. A later study by Hunteret al. assessed 286pneumatic tool

workers, and noted elbow OA in 10.5%. The authors concluded,

however, that there was no convincing evidence for this being

caused by pneumatic tools. They also noted that there was

no increase in frequency of OA in patients using tools with

higher vibration frequencies [6]. Lawrence showed no statistical

significant difference in the incidence of elbow OA in coal miners

who used pneumatic drills for 1 year (31%) compared to those

who did not use this equipment (16%). He concluded that thedevelopmentof elbowarthritis wasa feature ofmosttypesof heavy

manual work that he investigated [7]. More recently, a significant

doseeffect relationship to the range of flexion and radiographic

changes in the dominant elbow, which was independent of age,

wasnotedinastudyof74malestonequarryworkerswhooperated

chipping hammers and rock drills [8].

Heavy nondrilling work has also been reported to be associated

with elbow OA. It has not been reported in light manual office

based workers, although it was noticed more commonly in

heavy coalmine workers [7,9]. A study from Sheffield showed the

prevalence of elbow OA to be 10.5% in heavy workers compared

to 2.2% in nonheavy workers, with the dominant arm more

frequently affected. The condition is also recognized in patients

with ambulatory problems, requiring the use of crutches. In this

group, the dominant extremity is involved in approximately 80%

to 90% of patients [10]. All these findings suggest that excessive

loading of the elbow is an important predisposing factor.

The part played by genetic factors in elbow OA is less clear,

although demographic studies have shown differences in the

incidence of the condition in different races. A positive family

history was not noted in patients with symptomatic elbow

OA [4].

2011 British Elbow and Shoulder Society

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E Primary elbow osteoarthritis Adla and Stanley

Table 1 Classification of primary elbow osteoarthritis

Symptoms Signs Radiographic findings

Mild Intermittent acute pain. Pain mostly onextension

Posterior tenderness,Pain on passive elbow extension sign of posterior

impingementROM: near normal, but may have fixed flexion

deformity of less than 30 . Flexion is usually normal

Small osteophytes on tip ofolecranon and orcoranoid

Moderate Pain worse with activitiesLocking of jointDeteriorating ROM

Tender posteriorly and sometimes anteriorly.Crepitus on gripping and forearm rotationROM: 30 to 120

Obvious osteophytesJoint line preservedOlecranon and coronoid

fossae thickened

Severe Constant pain requiring regular analgesiaPain throughout ROMStiffness and crepitus

Generalized joint tendernessCrepitus and pain throughout ROMROM: 50 to 110

Obvious osteophytesJoint line narrowedLoss of the outline of

olecranon and Coranoidfossae

ROM, range of motion.

NATURAL HISTORYANDCHANGES INELBOW

OSTEOARTHRITIS

Goodfellow and Bullough studied the age related changes in

the elbow joint in 28 cadavers. They noticed a certain pattern

of degeneration and wear in the radiohumeral joint which was

considered to be the result of a combination of rotation and hinge

movements. By contrast, the ulnohumeral articulation, which has

hingemovementonly, showed onlyminorlinearwear changes [11].

Age-related changes appear to start on the radial aspect of the

elbow and gradually progress to the ulnohumeral joint, as a

result of excessive load concentrations occurring at the centre

of the joint. These findings were confirmed in another cadavericstudy [12] and similar intra-operative observations have been

recorded [13,14].

More recently, a casecontrol study comparing radiographic

changes at the elbow joint in patients with elbow osteoarthritis

with age- and sex-matched individuals showed that joint nar

rowing at the radiocapitellar joint was the third most common

findinginOApatients.Thechangesintheosteoarthritisgroupwere

predominantly of osteophyte formation, involving the olecranon,

coronoid and radial head in descending order. The classic features

of osteoarthritis with joint space narrowing and cyst formation

are late and uncommon findings in the elbow. Loose bodies and

thickening of the olecrenon fossa membrane were also frequentlynoted [15].

A histopathological study of the elbow confirmed thickening

of all components of olecranon fossa membrane (anterior cortical

bone, medullary cavity, posterior cortical bone, and anterior and

posterior fibrous tissue) in patients with osteoarthritis of theelbow

compared to a control group [16].

The histological and radiographic changes in the osteoarthritic

elbow help to explain the pattern of presentation, which is

predominantly related to impingement and loose body formation,

causing mechanical symptoms.

Clinicalpresentation

The usual mode of presentation is pain, reduced movement

and locking. The clinical presentation can be broadly classified

as mechanical, which may be in mild, moderate, severe stages

(Table 1), or neurological from ulnar neuropathy.

Mild

Patients withmild disease mostfrequentlypresent withdull aching

pain in theelbowwithintermittent episodes of acute pain. Patients

frequently have a near normal range of motion (ROM), although,

when a deficit is present, it is usually a fixed flexion deformity of

less than 30. There may be early ulnohumeral impingement as a

result of osteophytes at thetip of theolecranonand coranoid,with

pain on terminal extension and tenderness in the paraolecranon

fossae (Fig. 1).

Moderate

In this stage, there is a progressive deterioration of ROM, with

episodes of locking andacutepain.The pain is worse with activities

that require heavy lifting or extension of the elbow. Patients often

describe, locking of the joint, which requires trick movements to

unlock the elbow, and usually indicating the presence of a loose

body [17]. On clinical examination,the elbow maybe swollen, with

tenderness over the posterior and anterior aspects. A reduction

in ROM to less than 30 of full extension to 120 flexion is

often present. Crepitus may be palpable on gripping and forearm

rotation, indicating degeneration of the radiocapitellar joint. The

symptoms at this stage are a result of osteophytes and loose

bodies, which can be confirmed by plain radiographs (Fig. 2).

Severe

In severe disease, there is significant reduction in the ROM and the

pain is more constant. Patients usually require regular analgesia


42 Shoulder and Elbow 2011 British Elbow and Shoulder Society. Shoulder and Elbow2011 3, pp 41 48


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Fig. 1 Patient initially underwent a tennis elbow release, but represented

withpainonextendingtheelbowandwithsignsofposteriorimpingement(mild osteoarthritis). Plain radiographs show heterotropic bone formation

at the surgical site but a computed tomography scan with elbow in

extension shows posterior impingement.

and significant night pain may be a feature. On examination, there

is reduction in the ROM to 50 to 110 of flexion, and crepitus

throughout the ROM is frequently noted. Reduction in joint space

and osteophytes are seen on plain radiographs (Fig. 3).

Ulnarneuropathy

Ulnar nerve irritation is commonly observed in patients with

elbow OA. Reduced sensation in the ulnar nerve distributionand weakness may be the sole presenting symptoms. Kashiwagi

reported an incidence of 40.3% in patients with elbow OA [18] and

a Japanese study on cubital tunnel syndrome noted evidence of

elbow OA > 30% of patients [19]. A recent case series of elbow

arthritisreportedulnarnerveirritationtobeashighas84% [20].The

irritation/entrapment is considered to be a result of osteophytes

or other space occupying lesions such as ganglions arising from

the elbow joint. A prevalence of 3% to 8% of medial elbow

ganglia as a cause of ulnar nerve compression has been reported

in patients presenting with cubital tunnel syndrome. This was the

third most common cause of ulnar nerve compression [21,22].

A rapid onset of ulnar nerve symptoms should raise the

suspicion of a ganglion and further imaging is appropriate before

surgery [22].

Investigations

Imaging modalities are used to confirm the diagnosis of elbow OA

and electrophysiological tests for assessing ulnar nerve function.

A standard plain radiograph of the elbow (anteroposterior and

lateral views) is sufficient to diagnose most cases of elbow OA. The

anteroposterior radiograph helps to assess the overall alignment

of the joint, ulnohumeral joint line, radiocapitellar joint line and

Fig. 2 Patient withmoderateelbow osteoarthritis. Plainradiographsshow

the osteophytes and the computed tomography scan shows a thickened

olecranon membrane.

radial head osteophytes. It also shows the loss of outline of

the olecranon fossa (indicating thickening of the membrane).Kashiwagi advocated a special radiographic view to assess the

fossa. This is performed with the elbow flexed to 60 and the

distal arm placed flat over the X-ray plate [18] (Fig. 4). The lateral

radiograph is useful in assessing osteophytes at the tip of the

olecranon and coronoid process, the ulnohumeral articulation and

loose bodies. A recent radiographic study showed that the most

common features in elbow OA were olecranon osteophytes (96%),

followed by osteophytes of the coronoid process (90%), radial

head (86%) and coronoid and radial fossae (64%) [15]. A more

recent three-dimensional computed tomography (CT) scan study

of 22 patients with elbow OA, to map the osteophyte distribution

confirmed that, in 95% of patients, the osteophytes involved theulnohumeral joint, whereas radiohumeral osteophytes were only

foundin 59%. Although cadaveric and biomechanical studies show

that theradiohumeral joint ismore proneto wear, theulnohumeral

joint is more markedly affected by osteophytes [23].

Loose bodies are a common cause for locking and they can

mostly be identified on a plain radiograph. Ward et al. reported a

sensitivity of 79%, a specificity of 69% and a diagnostic accuracy

of 75% for plain radiography of loose bodies in the elbow [24].

A more recent comparison of plain radiography with arthroscopy

yielded a sensitivity of 84% and a specificity of 71%. Plain




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Fig. 3 Patientwith severeelbowosteoarthritis,with jointspacenarrowing.

radiography had a similar sensitivity and specificity to CT

arthrography and magnetic resonance imaging (MRI) (overall

sensitivity for the detection of loose bodies in either compartment

was 88% to 100% with a specificity 20% to 70%) [25].

Correlating theclinical symptoms and signs with theradigraphic

features is helpful in planning treatment because mild andmoderate stage disease can be managed by debridement

procedures. In early stage OA, the radiographs may show small

osteophytes on the tip of olecranon or coranoid with thickening of

the olecranon fossa membrane (Fig. 1). In moderate stage OA, the

osteophytes aremore obvious, although thejointline remains well

preserved (Fig. 2). In severe stages of OA, there is a clear reduction

in the joint space, which initially affects the radiocapitellar joint

and, subsequently, the ulnohumeral articulations (Fig. 3).

CT scans of the elbow with three-dimensional reconstructions

help visualize shelf osteophytes, in the olecranon, radial and

Fig. 4 Kashiwagi view: anteroposterior view of elbow taken with theelbow flexed to 60 and arm resting flat on the plate. The olecranon fossa

is clearly demonstrated.

the coronoid fossae. CT scanning with the elbow in maximal

extension identifies impingement of the tip of the olecranon on

the membrane of the fossa. The relationship of osteophytes to the

ulnar nerve is important with respect to surgical planning [26].

Both MRI and CT arthrography have excellent sensitivity (92%to 100%) but low to moderate specificity (15% to 77%) for

identifying posteriorly-based loose bodies. Neither MRI, nor CT

arthrography is consistently sensitive (46% to 91%) or specific

(13% to 73%) in predicting thepresenceor absence of loose bodies

anteriorly. In view of the invasive nature of CT arthrography, MRI

is preferable [25]. In addition, MRI is of help in diagnosing non-

calcified loose bodies and assessing the articular carilage [27].

Ultrasound examination of the ulnar nerve is a well recognized

technique for assessing the thickness of the nerve, site of

compression and presence of other lesions such as ganglions.

TREATMENTNon-operative

Once thediagnosis is made, patients shouldreceive an explanation

as to the cause of the symptoms and adviced on the natural

history. Symptomatic treatment, aiming to control pain, is the

first line of management. This is more appropriate for patients

with mild stage disease, who have no significant limitation of

activities of daily living or work. The main stay of initial treatment

is analgesics and anti-inflammatory medication. In the event of

failure of this approach, consideration may be given to the use

of steroid/viscosupplement injections. This is based solely on the




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practice of using this technique in other joints. We are unaware

of any studies showing it to be of benefit in the elbow joint. A

recent case series of 19 patients with post-traumatic elbow OA,

who received three intra-articular sodium hyaluronate injections

at regular intervals over 4 weeks, showed minimal improvement

in pain at 3 months, and no improvement at 6 months [28].

Operative treatmentSeveral surgical treatmentscan be consideredwhen non-operative

measures fail to control symptoms.Thesecan be divided into open

or arthroscopic techniques, all of which aim to reduce pain and

achieve some improvement in ROM. The decision on the choice of

method depends on the stage of presentation and the surgeons

skill and the familiarity with the different techniques.

Open techniques

Posterior approach (ulnohumeral arthroplasty). The Outer-

bridgeKashiwagi procedure was first described by Kashiwagi

in 1978 [18,29]. The procedure is performed through a posterior

triceps splitting approach with fenestration of the olecranon fossa(1 cm to 1.5 cm) being performed to gain access to the anterior

aspect of the elbow. The osteophytes on the olecranon and the

coronoid process are excised (Minami and Ishii, 1986). Morrey

modified the procedure and described the use of a trephine to

fenestrate the olecranon fossa. He followed up 15 patients over

a mean of 33 months and reported excellent results in 87% [30].

Theresults of ulnohumeral arthroplastyhave been reported in sev-

eral studies and are summarized in Table 2. Some of the patients

reported by Antuna et al. also had an anterior capsular release

through the fenestration or by a column procedure [14].

Long-term results of ulnohumeral arthroplasty have remained

encouraging. Minami et al. reviewed the results of this arthroplasty

in 44 elbows followed for 8 years to 16 years. They reported 61%patients had slight or no pain at final review but noted 10%

deterioration in ROM, when the same group was compared at

5 years and 12 years after initial surgery [36].

Complications. Complications that have been reported following

open ulnohumeral arthroplasty include ulnar nerve entrapment,

ulna nerve neuropraxia/irritation [14,37], anterior interosseous

nerve palsy [35], superficial wound infection, hematoma [37],

myositis ossificans and triceps rupture [35]. A reoperation rate

of 8% has also been reported [37].

Despite clinical success, radiographic signs of recurrence in the

fenestrated area at the olecranon and coronoid fossae are know to

occur. The rate of this recurrence increases with time. Wada et al.

found recurrence of osteophytes in both the olecranon and the

coronoid fossae in 100% of patients followed for 10 years or more.A correlation between radiographic signs of recurrence and func-

tional outcome has not been firmly established. However, theslow

reformationoftheolecranonfossamembraneandosteophytesthat

hasbeennotedmayexplainthedelayinrecurrenceofimpingement

symptoms despite obvious radiographic changes [20,36,38].

Prognostic factors to predict the outcomes of ulnohumeral

debridement have been suggested. Duration of symptoms of less

than 2 years, pain scores of 2 or 3 (no pain, 0; occasional or mild

pain, 1; regular pain requiring analgesia, 2; severepain notrelieved

by analgesia, 3), and the presence of cubital tunnel syndrome

were associated with an increased chance of a good outcome. The

absence of pre-operative locking was associated with an increased

chance of a poor outcome, although a history of trauma, the

pre-operative ROM and number of loose bodies did not affect the

outcome [37].

Posteromedial approach. Wada et al. described a posteromedial

approach for debridement of the arthritic elbow. They reported

the results in 32 patients, with a mean duration of follow-up of

121 months, of which 19 elbows were followed for more than

10 years. Twenty-eight (85%) patients reported no pain and five

had mild pain. The mean arc of movement improved by 24. The

mean Japanese Orthopaedic Association elbow score improved by

23 points. Of 25 patients who had performed heavy manual work,76% returned to their previous job or an equivalent job. In the

elbows followed formore than 10 years,the limitationof extension

hadincreased by 7 with nochange in flexion.The lossof extension

was attributed to the recurrence of osteophytes at the olecranon

process (47%) and the olecranon fossa (47%). Wada advocated

this approach for patients with degenerativearthritis whoalso had

ulnar nerve symptoms requiring decompression [20].

Table 2 Open ulnohumerl arthroplasty

Reference Year Numberof elbows PrimaryOA% Meanage Follow-up(months) Improvementin ROM Satisfaction(subjective) MEPS (good-excellent) Complicationrate Reoperationrate

Forster et al. [38] 2001 36 65 57 39 25 81% 17% 8%Antuna et al. [14] 2002 46 100 48 80 20 74% 74% Phillips et al. [32] 2003 20 100 51.4 75 20 65% Sarris et al. [33] 2004 17 95 52 36 32 Allen et al. [34] 2004 9 89 45 26 21 11% Vingerhoeds

et al. [35]2004 16 20 20 86.6% 87.5%

Hearnden et al. [36] 2009 59 67 63 92 18 63% 60% 24% 3.3%

OA, osteoarthritis; MEPS, Mayo Elbow Performance Score; ROM, range of motion.




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Posterolateral approach. Tsuge and Mizuseki described an

extensive debridement arthroplasty though a posterolateral

approach in 29 elbows, with an average follow-up of 5 years. The

ulnar nerve was decompressed, the triceps and periosteum of the

olecranonreflected, and thejoint dislocated by dividing the lateral

collateral ligament. Pain was relieved in all cases, although some

patients complained of dullaching on firm gripping.Impingement

in flexion and extension was noted at 5 years and most patients

returned to their former occupation [13].

Oka et al. compared patients who had a lateral (20 patients),

medial(10patients)andacombinedmedialandlateralapproaches

(eight patients) over a mean of 5.9 years. No significant differences

in the outcomes were noted between the groups [39].

Arthroscopic techniques. Arthroscopy of the elbow has evolved

with the advances in arthroscopic equipment and surgical

techniques. It has become a more popular, safer and more

effective treatment option for many elbow problems. Arthroscopic

debridement of osteophytes and removal of loose bodies alone

has shown promising results [40]. Arthroscopic modification of the

OuterbridgeKashiwagi procedure has also been described. Thisprocedure involves arthroscopic excision of the osteophytes and

fenestration of the olecranon fossa. A study of 12 patients who

underwent this procedure reported improvement in symptoms in

all patients, although significant improvements in ROM was not

noted [41]. Inclusion of anterior and posterior capsular releases

has been suggested to improve the ROM in the elbow [42]. Some

studies have also included excision of the radial head [43,44].

Cohen et al. compared the results of arthroscopic (20) and open

(15) debridement for primary OA of the elbow. Both procedures

were surgically effective but no difference was noted in the

patient perceived benefit between the two groups, although the

range of flexion was slightly better in the open group at mean

follow-up of 35.3 months [45]. More recent studies of arthroscopic

debridement have shown some improvement in the ROM

(Table 3). One study by Krishnan et al. has reported far greater

improvement in ROM than the other arthroscopic studies and the

published data from open procedures [46]. This study is of interest

because the mean age of the patients was younger (36 years as

opposed to>50 years) and therefore may not reflect the outcome

that canbe expected in themore usual older aged patient with this

condition.

Debate remains as to whether radial head excision should be

combined with the arthroscopic procedure. Kelly advised against

it even in the presence of radiocapitellar arthritis [47], whereas

McLaughlinet al.feltthiswasanimportantaspectoftheprocedure.

They reported the results of arthroscopic radial head excision with

or without ulnohumeral arthroplasty in 36 patients with elbow

arthritis (10 primary, 26 secondary). Twenty-eight patients had an

ulnohumeral arthroplasty andradial head excision andthe rest had

only a radial head excision. They noted better outcome scores and

arc of motion in those who had radial head excision alone (62)

compared to patients who had a combined procedure (46) [44].

Complications after elbow arthroscopy are more common than

other joint arthroscopies as a result of the close proximity of

the neurovascular structures. The most common complication is

transient nerve palsy, which occurs in up to 14% of reported

series [42 48]. Various techniques have been suggested to

reduce neurological complications after elbow arthroscopy [42].

Other complications include deep infection (0.8%) in patients

who had steroid injections postoperatively [47] and myositis

ossificans [48,49].

Ulnar nerve symptoms. Most authors recommend simple

decompression of the ulnar nerve, although anterior transposition

is advisable in patients with a fixed flexion deformity of>60, andwhen there is a space occupying lesion such as a ganglion in

the cubtal tunnel [22]. Cubital tunnel reconstruction by excision

of the medial osteophytes and deepening the cubital tunnel

has been advocated and reported to produce encouraging

results [50].

Arthroplasty. Totalelbow arthroplastyhas been successfully used

to treatlow demand patients with inflammatoryarthritis, although

is not routinely recommended for primary OA. There is a paucity

of literature regarding prosthetic replacement for this condition.

One report of linked prosthesis used in five patients (mean age

68 months), with a minimum assessment of 3 months (range

37 monthsto 125 months) reported complicationsin four patients.

These included subluxation, fractureof a humeral componentwith

particulatesynovitis, heterotopic ossification, recurrent osteophyte

formation, and transient ulnar neuropathy [51]. Another series

using unlinked SouterStrathclyde total elbow arthroplasties in

nineelbowsreportedasymptomaticradiologicallooseninginthree

humeral and twoulnar components. One patient required revision

for loosening and failure at a mean follow-up of 68 months (range

15 months to 117 months) [52].

Other procedures. Other procedures, to reduce elbow pain have

been described, although these have not been widely adopted.

Table 3 Arthroscopic procedures

Reference YearNumber

of elbowsPrimary

OA%Meanage

Follow-up(months)

Improvementin ROM

Satisfaction(subjective)

MEPS (good-excellent)

Complicationrate

Krishnan et al. [47] 2007 11 100 36 26 73 100% 100% Kelly et al. [48] 2007 25 51 67 21 90% nilAdams et al. [49] 2008 42 100 52.8 40.6 35 78.6% 81% 4.7% (one hetrotopic)

OA, osteoarthritis; MEPS, Mayo Elbow Performance Score; ROM, range of motion.




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Bateman described denervation of the elbow in a small group of

patients with elbow pain and reported improvement in pain in

most patients [53].

Distraction interposition arthroplasty has also been used for

young patients with post-traumatic elbow OA, although there are

no published data available on this technique in primary OA [26].

References

1. Huskisson EC, Dieppe PA, Tucke AK, Cannell LB. Another look atosteoarthritis.Ann Rheum Dis 1979; 38:4238.

2. Doherty M, Preston B.Primaryosteoarthritisoftheelbow.AnnRheumDis 1989; 48:7437.

3. Williams WV, Cope R, Gaunt WD, et al. Metacarpophalangealarthropathy associated with manual labor (Missouri metacarpalsyndrome). Arthritis Rheum 1987; 30:136271.

4. Stanley D.PrevalenceandEtiologyofsymptomatic elbowosteoarthri-tis.J Shoulder Elbow Surg 1994; 3:386 9.

5. Rostock P. Gelenkschaden durch arbeiten mit presluftwerkzeugenund andere. Rorperliche Arbeit Medizinische Klinik1936; 11:3413.

6. Hunter D, McLaughlin A, Perry K. Clinical effects of the use ofpneumatic tools. BrJIndMed1945; 2:10 6.

7. Lawrence JS. Rheumatism in coal miners. III. Occupational factors.

BrJ Ind Med1955; 12:24961.8. Sakakibara H, Suzuki H, Momoi Y, Yamada S. Elbow joint disordersin relation to vibration exposure and age in stone quarry workers. IntArch Occup Environ Health 1993; 65:9 12.

9. Mintz G, Fraga A. Severe osteoarthritis of the elbow in foundryworkers. Arch Environ Health 1973; 27:7880.

10. Morrey BF. Primary osteoarthritis: ulnohumeral arthroplasty. In:Morrey BF, ed. The elbow and its disorders. vol. 76. Fourth edition.Philadelphia, PA: WB Saunders, 2008:104354.

11. Goodfellow JW, Bullough PG. The pattern of ageing of the articularcartilage of the elbow joint. J BoneJoint SurgBr1967; 49:17581.

12. Murata H, Ikuta Y, Murakami T. Anatomicinvestigationof theelbowjoint with specific reference to aging of the articular cartilage.J Shoulder Elbow Surg 1993; 2:17581.

13. Tsuge K, Mizuseki T. Debridement arthroplastyfor advancedprimary

osteoarthritis of the elbow. J BoneJoint SurgBr1994; 76-B:6416.14. Antuna SA, Morrey BF, Adams RA, ODriscoll SW. Ulnohumeralarthroplasty for primary degenerative arthritisof the elbow: long-termoutcome and complications. J BoneJoint SurgAm 2002; 84:216873.

15. Dalal S, Bull M, Stanley D. Radiographic changes at the elbow inprimary osteoarthritis: a comparison with normal aging of the elbowjoint. J Shoulder Elbow Surg 2007; 3:35861.

16. Suvarna SK, Stanley D. Thehistologic changes of theolecranonfossamembrane in primary osteoarthritis of the elbow. J Shoulder ElbowSurg 2004; 5:555 7.

17. Stanley D. Primary osteoarthritis of the elbow. In: Stanley D, Kay NRM,eds. Surgeryoftheelbowpracticalandscientificaspects.London:Arnold,1998:35465.

18. Kashiwagi D. Osteoarthritis of the elbow joint-intraaricular changesand the special operative procedure. Outerbridge Kashiwagi method.

In:Elbow jointKashiwagi D (ed).Amsterdam:Elsevierscience publisherBV (Biomedical devision), 1985:177 88.19. Ikuta I, Sugata I, Tsuge K. Treatment of cubital tunnel syndrome

(Japanese). Saigaiigaku 1977; 20:44754.20. Wada T, Isogai S, Ishii S, Yamashita T. Debridement arthroplasty

for primary osteoarthritis of the elbow. J Bone Joint Surg Am 2004;86A:23341.

21. Gay JR, Love JG. Diagnosis and treatment of tardy paralysis of theulnar nerve. Based on a study of 100 cases. J Bone Joint Surg 1947;29:108797.

22. Kato H, Hirayama T, Minami A, Iwasaki N, Hirachi K. Cubital tunnelsyndrome associated with medial elbow ganglia and osteoarthritis ofthe elbow. J BoneJoint SurgAm 2002; 84:14137.

23. Lim YW, van Riet RP, Mittal R, Bain GI. Pattern of osteophytedistribution in primary osteoarthritis of the elbow. J Shoulder ElbowSurg 2008; 17:9636.

24. Ward WG, Belhobek GH, Anderson TE. Arthroscopic elbowfindings:correlation with preoperative radiographie studies.Arthroscopy1992;8:498502.

25. Dubberley JH, Faber KJ, Patterson SD, et al. The detection of loosebodiesin theelbow:the valueof MRIand CT arthrography.J Bone JointSurg Br2005; 87:6846.

26. Cheung EV, Adams R, Morrey BF. Primary osteoarthritis of theelbow: current treatment options. J Am Acad Orthop Surg 2008; 16:7787.

27. Brunton LM, Anderson MW, Pannunzio ME, Khanna AJ,Chhabra AB. Magnetic resonance imaging of the elbow: updateon current techniques and indications.J Hand Surg 2006; 31:1001 12.

28. van Brakel RW, Eygendaal D. Intra-articular injection of hyaluronicacid is not effective for the treatment of post-traumatic osteoarthritisof the elbow. Arthroscopy2006; 22:1199203.

29. Kashiwagi D. Intra-articular changes of the osteoarthritic elbow,especially about the fossa olecranon. Jpn Orthop Assoc 1978;52:136782.

30. Minami M, Ishii S. Outerbridge-Kashiwagi arthroplastyfor ostearthri-tis of the elbow joint. In: Elbow joint Kashiwagi D (ed). Amster-dam; Elsevier science publisher BV (Biomedical devision); 1985:

18996.31. Morrey BF.Primary degenerative arthritis of the elbow. Treatment by

ulnohumeral arthroplasty. J BoneJoint SurgBr1992; 74:40913.32. Phillips NJ, Ali A, Stanley D. Treatment of primary degenerative

arthritis of the elbow by ulnohumeral arthroplasty. A long-termfollow-up. J BoneJoint Surg Br2003; 85:34750.

33. Sarris I, Riano FA, Goebel F, Goitz RJ, Sotereanos DG. Ulnohumeralarthroplasty: results in primary degenerative arthritis of the elbow.Clin Orthop 2004; 420:1903.

34. Allen DM, Devries JP, Nunley JA. Ulnohumeral arthroplasty. IowaOrthop J2004; 24:4952.

35. Vingerhoeds B, Degreef I, De Smet L. Debridement arthroplasty forosteoarthritis of the elbow (OuterbridgeKashiwagi procedure). Actaorthop Belg 2004; 70:30610.

36. Hearnden A, Talwalkar SC, Roy N, et al. Ulnohumeralarthroplastyin

the management of the arthritic elbow. Shoulder Elbow2009; 1:95 8.37. Minami M, Kato S, Kashiwagi D. Outerbridge Kashiwagi methodfor arthroplasty of osteoarthritis of the elbow. 44 elbows followed for816 years. J Orthop Sci1996; 1 11.

38. Forster MC, Clark DI, Lunn PG. Elbow osteoarthritis: prognostic indi-cators in ulnohumeral debridement the OuterbridgeKashiwagiprocedure. J Shoulder Elbow Surg 2001; 10:55760.

39. Gramstad GD, Galatz LM. Management of elbow osteoarthritis.J Bone Joint Surg Am 2006; 88:42130.

40. Oka Y, Ohta K, Saitoh I. Debridement arthroplasty for osteoarthritisof the elbow. Clin Orthop 1998; 351:12734.

41. Ogilvie-Harris DJ, Gordon R, MacKay M. Arthroscopic treatmentfor posterior impingement in degenerative arthritis of the elbow.Arthroscopy1995; 11:43743.

42. Redden JF, Stanley D. Arthroscopic fenestration of the olecranon

fossa inthe treatmentof osteoarthritisof theelbow.Arthroscopy1993;9:146.43. ODriscoll SW. Arthroscopic treatment for osteoarthritis of the elbow.

Orthop Clin North Am 1995; 26:691706.44. Savoie FH, Nunley PD, Field LD. Arthroscopic management of the

arthritic elbow: Indications, technique, and results. J Shoulder ElbowSurg 1999; 8:214 9.

45. McLaughlin RE II, Savoie FH III, Field LD, Ramsey JR. Arthroscopictreatmentof thearthriticelbowdue to primary radiocapitellararthritis.Arthroscopy2006; 22:63 9.

46. Cohen AP, Redden JF, Stanley D. Treatment of osteoarthritis ofthe elbow: a comparison of open and arthroscopic debridement.Arthroscopy2000; 16:7016.




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47. Krishnan SG, Harkins DC, Pennington SD, Harrison DK,Burkhead WZ. Arthroscopic ulnohumeral arthroplasty for degen-erative arthritis of the elbow in patients under fifty years of age.J Shoulder Elbow Surg 2007; 16:4438.

48. Kelly EW, Bryce R, Coghlan J, Bell S. Arthroscopic debridementwithout radial head excision of the osteoarthritic elbow. Arthroscopy2007; 23:151 6.

49. Adams JE, Wolff LH III, Merten SM, Steinmann SP. Osteoarthritisof the elbow: results of arthroscopic osteophyte resection and

capsulectomy. J Shoulder Elbow Surg 2008; 17:12631.50. Gofton WT, King GJ. Heterotopic ossification following elbow

arthroscopy. Arthroscopy2001; 17:E2, 1 5.

51. Tsujino A, Itoh Y, Hayashi K, Uzawa M.Cubitaltunnelreconstructionfor ulnar neuropathyin osteoarthritic elbows.J Bone JointSurg Br1997;79B:3903.

52. Kozak TK, Adams RA, Morrey BF.Totalelbowarthroplastyinprimaryosteoarthritis of the elbow. J Arthroplasty1998; 13:83742.

53. Espag MP, Back DL, Clark DI, Lunn PG. Early results of theSouter Strathclyde unlinked total elbow arthroplasty in patientswith osteoarthritis.J Bone Joint Surg Br2003; 85:3513.

54. Bateman JE. Denervation of the elbow joint for the relief of pain-a

preliminary report. J BoneJoint SurgBr1948; 30:63541.



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