Single arthroscopic procedure beats combined approach for elbow arthritis

Patients treated with radial head excision alone increased their average Andrews-Carson score about 100 points.

Arthroscopic radial head excision, performed alone, may provide patients who have radiocapitellar elbow arthritis with better postop pain relief and function than radial head excision combined with ulnohumeral arthroplasty, a retrospective study suggests.

Robert E. McLaughlin II, MD, and colleagues at the Mississippi Sports Medicine Center in Jackson, reviewed the results of 36 such patients treated with either early radial head excision alone (eight patients) or late radial head excision combined with ulnohumeral arthroplasty (28 patients). Patients averaged 45.7 years of age and all had failed conservative treatments, including NSAIDs, physical therapy and protective bracing, according to the study.

Surgeons performed all procedures arthroscopically. For radial head excision, surgeons entered the elbow through an anterior proximal medial portal with the patient's elbow flexed at 90°, creating a proximal lateral instrument portal. They then removed any loose bodies and arthritic debris and performed an anterior synovectomy before debriding osteoarthritic spurs from the coronoid process. The anterior aspect of the radial head was then excised using a shaver, and arthritic spurs and loose bodies were debrided from the olecranon fossa, according to the study.

After radial head excision, patients in the combined procedure group were treated with the Outerbridge-Kashiwagi procedure, which focuses on the olecranon fossa. Surgeons used a drill to connect the olecranon fossa to the coronoid fossa. Using an arthroscopic burr, they then enlarged the opening to at least 2 cm in diameter or until allowing full flexion and extension. The procedure ended once surgeons encountered the medial and lateral columns of the distal humerus, according to the study.

Postoperative follow-up ranged from 18 to 91 months and averaged 52 months. At final follow-up, radial head excision-only patients had significantly better improvements in flexion, extension and total arc of motion (P=.002).

Preoperatively, excision-only patients had 112° average flexion, –38° average extension and 74° average total arc of motion. At final follow-up, average flexion improved 29° to 141°, average extension loss improved 38° to 0° and total arc of motion increased 62°, according to the study.

Patients treated with the combined procedure had an average preop flexion of 112°, an average preop extension of –33° and an average preop total arc of motion of 79°. At final follow-up, flexion increased 19° to average 131°, extension loss improved 27° to average 6° and total arc of motion increased 46°, according to the study.

Excision-only patients also had better Andrews-Carson rating scale (A-C) scores, which improved from a preop average of 72 points to an average of 170 at final follow-up. Comparatively, combined-procedure patients had an average preop A-C score of 92 points, which improved to 150 points at final follow-up.

“We believe that this is a significant finding. Patients undergoing radial head excision alone increased their average A-C almost 100 points, going from a rating of poor to good. Those undergoing both procedures only increased their score an average of 58 points,” the authors said in the study.

“In addition, those undergoing only radial head excision had a 20-point higher average overall postoperative A-C rating than those undergoing both procedures, while starting at a lower functional level. [This] information suggests that patients treated early in the disease process had greater success overall than those who chose to receive later treatment,” they said. “It also suggests that a more significant improvement in function is found in patients treated early.”

All excision-only patients and 26 of the 28 combined-procedure patients reported satisfaction and significant improvement in pain, defined as a increase of two or more Visual Analog Scale levels.

The remaining two combined-procedure patients required a return to surgery: one for a contracture release and one for a radial head replacement due to intractable pain, according to the study.

For more information:
McLaughlin RE, Savoie FH, Field LD, Ramsey JR. Arthroscopic treatment of the arthritic elbow due to primary radiocapitellar arthritis. Arthroscopy. 2006;22:63-69.