Management of Severe Elbow Arthritis in a Young Patient

Elbow osteoarthritis is occasionally primary and most often post-traumatic. Nonoperative treatment is frequently the best course of action. Available surgical options are governed by the location of cartilage deterioration, bone structure, and preoperative joint instability. Debridement of osteophytes can achieve modest, temporary increases in motion and comfort. Surgical management benefits from knowledge of the substantial varus torque that is exerted when the arm is abducted. In the elbow that is resurfaced or replaced, these forces may strain the soft tissue support and lead to premature subluxation and failure. Understanding the influence of these forces may improve clinical outcomes. Interposition arthroplasty can restore mobility to a stiff elbow with advanced posttraumatic arthritis and adequate medial and lateral columns of the distal humerus, but the elbow may subluxate with varus stress (shoulder abduction) or progressive loss of the bone. When the bone structure and cartilage of the distal humerus are damaged and the ulna is spared, then elbow hemiarthroplasty can be considered. Both interposition arthroplasty and elbow hemiarthroplasty benefit from restoration of soft tissue elbow support to prevent postoperative subluxation. Elbow hemiarthroplasty is currently not a US Food and Drug Administration-approved procedure. In exceptional cases, it has been used off-label. When both sides of the ulnohumeral joint have substantial loss of their bone architecture, total elbow arthroplasty can be considered. It is desirable to avoid total elbow arthroplasty in healthy, active patients, who are the vast majority of people with posttraumatic or primary elbow arthritis. Although this can work in elderly, low-demand patients, the worst results are in young, active patients. Four surgical options and barriers to future management options are discussed.