Page 21 - ISAKOS 2018 Winter Newsletter

Radiocapitellar Arthritis
MRI might reveal subchondral edema and / or intra-articular effusion. In all cases, the examiner has to pay attention not to overlook signs of joint laxity or instability, which may be present as well.
Treatment
Therapeutic options are limited in cases of symptomatic radiohumeral arthritis. Frequently, rest and pain-relief measures provide only a temporary effect. The use of NSAIDs has a long-standing tradition in the treatment of arthritic pain. Possible adverse events such as interactions with aspirin, upper GI bleeding, and nephrotoxicity are well known, somewhat limiting their potential for long-term pain reduction. Cortisone injections do not result in substantial long-term improvement for arthritic joints. Platelet-rich plasma (PRP) has been demonstrated to not provide a reproducible benefit when used for the treatment of joint abnormalities. Physiotherapy may enable the patient to maintain motion and strength.
Arthroscopy
As the least-invasive operative treatment available, arthroscopy is often performed to debride chondral flaps, osteophytes, loose bodies, and synovitis. Moreover, arthroscopy can be used to perform microfracture surgery. We commonly use the 4.0-mm scope in the high posterolateral portal, looking down on the radial head and into the radiocapitellar joint to visualize the pathology. Instruments are brought into the joint through the soft spot portal, slightly above the radial head. From there, the debridement can be performed and the state of degeneration of the joint can be determined. Stability testing also can be performed by investigating the congruency of the radiocapitellar, radioulnar, and humeroulnar joints. Microfracture of the radial head and capitellum is done either via the soft spot or through additional percutaneous portals. Bringing in the camera through the anteromedial portal and using the anterolateral portal for instrumentation allows a thorough investigation of the ventral aspect of the radiocapitellar joint. Chondral flaps and osteophytes can be debrided from there.
If localized, significant chondral defects are present, microfracture is an established means of treatment. The goal of microfracture is to open the subchondral bone in order to allow mesenchymal stem cells to reach the chondral surface, fill the void, and generate new chondral tissue (fibrocartilage) that can assist in taking part of the articular load. To create the holes in the subchondral bone, we use 1.4 to 1.6-mm K-wires, which are introduced in an oscillating mode. A major task is to reach the articular surface with the drilling device in the correct angle. A flat angle can result in sliding of the K-wire, leading to “keying” of the surface (Fig. 1).
Introduction
Kilian Wegmann, MD, PhD
Cologne, GERMANY
Lars Peter Müller, Prof.
GERMANY
Gregory Ian Bain, MBBS, FRACS, PhD
AUSTRALIA
Arthritis of the elbow can be a debilitating pathology. This condition can present idiopathically or as secondary degenerative changes. Secondary arthritis often develops after trauma—for example, when fractures or other injuries result in incongruency or regional defects in the articular surfaces. The most common type of fracture around the elbow, with an annual incidence of as high as 2.8 per 10,000, is a fracture of the radial head. Hence, secondary arthritis of the radial head and the capitellum are common sequelae. Radiohumeral arthritis is also found in individuals who perform strenuous manual labor. Patients often complain about painful crepitus during rotation of the forearm, night pain, and pain after rest. Radial-sided pain can be induced by forceful muscle contraction of the forearm, which compresses the radiocapitellar joint. Often, these patients are young, active males with manual occupations.
Assessment
Clinical investigation will show pain on compression of the radiocapitellar joint space. The osteochondral shear test, also known as the active radiocapitellar compression test, will be positive. This test is performed by applying compression while pronating and supinating the extended forearm. Radiographs and CT scans will show fraying of the joint surfaces. Depending on the level of progression, subchondral cysts and osteophytes may be seen.
CURRENT CONCEPTS
ISAKOS NEWSLETTER 2018: VOLUME I 19