Orthopaedic Surgery - Elbow Arthritis

Basics

The elbow may be affected by both inflammatory and noninflammatory arthropathies.

Regardless of the underlying cause, elbow arthritis commonly produces pain, weakness, stiffness, and progressive loss of motion.

The clinical pattern varies depending on whether the arthritis is primary degenerative, post-traumatic, inflammatory, infectious, or crystalline.

Epidemiology

Elbow arthritis is relatively uncommon compared with arthritis of weight-bearing joints.

Primary osteoarthritis accounts for only approximately 1–2% of elbow arthritis, while most remaining cases are related to inflammatory disease or previous trauma.

The condition can occur at any age, depending on the cause, and males and females are affected overall at roughly similar rates.

Total Elbow Arthroplasty and Age

Because total elbow arthroplasty carries lifelong restrictions on repetitive loading and heavy lifting, it is generally favored for older, lower-demand patients, commonly those over approximately 60 years of age.

Joint-preserving procedures are preferred whenever practical in younger and more active individuals.

Risk Factors

Important risk factors include rheumatoid arthritis, previous septic arthritis, crystalline arthropathy, hemophilia, and prior elbow trauma.

Repeated heavy use of the elbow may also contribute to primary osteoarthritis.

Etiology

The major causes of elbow arthritis include inflammatory arthropathy and trauma.

Primary osteoarthritis occurs less commonly and is typically associated with long-term repetitive loading.

Clinical Presentation

General Symptoms

Elbow arthritis usually presents with a combination of pain and restriction of motion.

The location and timing of pain during the arc of movement can provide clues regarding the stage and cause of disease.

Primary Osteoarthritis

Primary elbow osteoarthritis is most commonly seen in individuals with a history of heavy repetitive upper-extremity use, such as manual laborers, weight lifters, and throwing athletes.

Early Disease

During the early stage, pain is commonly produced at the terminal limits of motion, especially terminal extension.

This usually results from impingement between osteophytes around the olecranon, coronoid process, and their corresponding fossae.

Motion may become restricted because of these mechanical blocks.

Advanced Disease

As degeneration progresses, pain may extend throughout the entire arc of elbow motion.

Pain that is no longer limited to terminal flexion or extension suggests more advanced articular involvement.

Post-Traumatic Arthritis

Post-traumatic arthritis may develop after virtually any injury to the elbow, even when the original trauma initially appeared relatively minor.

Fractures involving the joint surface, instability, malalignment, cartilage injury, or previous dislocation may accelerate degeneration.

Sources of Pain

Pain in post-traumatic arthritis may arise from articular degeneration, osteophyte impingement, stiffness, or associated nerve entrapment.

Functional Limitations

Activities that place traction or load across the elbow, such as carrying a bag or briefcase, may become difficult and may be tolerated only briefly.

Late Changes

As disease progresses, the patient may develop substantial reduction in motion and a persistent flexion contracture.

Pain may become present during much of the available range.

Radiographic Findings

AP and lateral radiographs may demonstrate osteophyte formation, subchondral sclerosis, joint irregularity, and loose bodies.

Inflammatory Arthritis

Inflammatory arthropathies can produce a similar loss of motion but often have a different pain pattern.

Pain is frequently present throughout the entire arc of movement, rather than being confined to terminal positions.

Advanced Inflammatory Disease

With progression, patients may lose both elbow flexion-extension and forearm pronation-supination.

Joint destruction may eventually produce deformity and instability.

Signs of Inflammation

Examination may reveal joint warmth, effusion, swelling, and synovitis.

During early inflammatory disease, plain radiographs may remain relatively normal because synovial inflammation and joint fluid precede significant osseous destruction.

Physical Examination

Inspection

The elbow should be inspected for previous surgical incisions, scars, skin grafts, areas of fibrosis, deformity, swelling, and muscular atrophy.

Previous surgery or trauma may influence both diagnosis and future surgical planning.

Range of Motion

Active and passive range of motion should be measured, preferably with a goniometer.

Measurements should include flexion, extension, pronation, and supination.

Comparison with the opposite elbow is useful.

Stability

Varus, valgus, and rotational stability should be assessed.

Associated ligamentous insufficiency may contribute to pain or alter the choice of treatment.

End Point of Motion

The examiner should determine whether restriction has a firm mechanical endpoint or a softer capsular endpoint.

Crepitus, catching, or locking should also be documented because these findings may indicate osteophytes or intra-articular loose bodies.

Early Findings

Pain and loss of range of motion are often the earliest clinical findings.

Effusion

An elbow effusion is generally easiest to appreciate on the lateral side of the joint, around the soft spot bounded by the lateral epicondyle, radial head, and olecranon.

Contracture

Chronic disease may result in fixed flexion or extension contracture.

Flexion contracture is especially common.

Ulnar Neuropathy

Late-stage arthritis may produce ulnar nerve compression or irritation, particularly when osteophytes, deformity, or valgus alignment narrow the cubital tunnel.

Patients may develop numbness or paresthesias in the ring and small fingers.

Ankylosis

Advanced destructive disease can ultimately result in severe stiffness or ankylosis of the elbow.

Laboratory Evaluation

Rheumatologic Studies

A rheumatologic evaluation should be performed when an inflammatory arthropathy is suspected.

The specific laboratory studies depend on the clinical context.

Joint Aspiration

Joint aspiration is important when infection or crystalline arthropathy is being considered.

Synovial fluid can be sent for cell count, differential, Gram stain, culture, and crystal analysis as appropriate.

Suspected Septic Arthritis

When septic arthritis is a concern, inflammatory markers such as ESR and C-reactive protein should be obtained in addition to aspiration and microbiologic studies.

Crystal Analysis

Synovial fluid should be examined for crystals when gout or calcium pyrophosphate deposition disease is suspected.

Imaging

Plain Radiographs

Routine imaging consists of AP and lateral radiographs of the elbow.

Additional views may be obtained when loose bodies, specific osteophytes, or deformity require further definition.

Pathological Findings

Rheumatoid Arthritis

Rheumatoid involvement typically produces symmetric joint-space narrowing, periarticular erosions, and diffuse osteopenia.

The proliferative synovium progressively destroys cartilage and subchondral bone.

Radial Head Destruction

In advanced rheumatoid arthritis, the radial head may become substantially eroded or destroyed.

Valgus deformity and instability may subsequently develop.

Primary Osteoarthritis

Primary osteoarthritis may initially preserve much of the central ulnohumeral and radiocapitellar joint space.

Characteristic abnormalities include osteophytes around the olecranon and coronoid processes and the development of loose bodies.

Differential Diagnosis

Septic Arthritis

Septic arthritis should be excluded in patients with acute severe pain, effusion, fever, systemic symptoms, or markedly elevated inflammatory markers.

It represents an urgent diagnosis.

Elbow Instability

Ligamentous instability can produce pain, clicking, apprehension, and functional loss that may mimic arthritis.

Tendinopathy

Medial or lateral epicondylitis and other tendon disorders can cause elbow pain without significant intra-articular degeneration.

Nerve Entrapment

Ulnar, radial, or median nerve compression around the elbow can cause pain and weakness and may coexist with arthritis.

Treatment

General Principles

Initial management is generally nonoperative.

Surgery should be reserved for patients with persistent disabling pain, substantial functional limitation, or mechanical symptoms despite appropriate conservative treatment.

Activity Modification

Activities should be adjusted according to symptoms.

Patients may need to reduce repetitive lifting, heavy resistance exercises, throwing, or other movements that provoke pain.

Nonoperative Treatment

Rheumatoid Arthritis

Treatment of rheumatoid arthritis includes appropriate systemic disease-modifying antirheumatic drugs (DMARDs), activity modification, physical therapy, bracing, and supportive devices.

Control of the systemic inflammatory disease is an important part of preserving joint function.

Osteoarthritis

Nonoperative management of elbow osteoarthritis may include rest, NSAIDs when tolerated, activity modification, physical therapy, and progressive or dynamic splinting.

Corticosteroid Injection

An intra-articular corticosteroid injection may be considered for selected patients whose symptoms persist despite oral anti-inflammatory treatment.

Relief may be temporary and repeated injections should be used judiciously.

Splinting

Dynamic or progressive static splints may help improve a flexion or extension contracture.

They are most useful when a substantial portion of the motion loss remains soft-tissue rather than fixed osseous restriction.

Radiotherapy

Radiosynovectomy

Radioactive synovectomy, or radiosynoviorthesis, involves sterile intra-articular administration of a radioisotope to suppress diseased synovium.

It has been used selectively for persistent inflammatory synovitis but is not a routine treatment for degenerative elbow arthritis.

Surgery

The appropriate procedure depends on patient age, activity level, cause of arthritis, degree of joint destruction, location of disease, motion loss, instability, and condition of surrounding soft tissues.

Synovectomy

Synovectomy may be considered in rheumatoid arthritis when persistent proliferative synovitis causes pain and progressive joint damage.

Removing inflamed synovium may improve symptoms and potentially slow local destruction in selected patients.

Arthroscopic Debridement

Arthroscopic debridement is commonly used for selected patients with degenerative arthritis.

The procedure can include removal of loose bodies and impinging osteophytes, together with capsular release when needed to improve extension.

Arthroscopy After Previous Trauma

Prior trauma or surgery may distort normal anatomy and increase the risk to nearby nerves during elbow arthroscopy.

This requires careful patient selection and experienced surgical technique rather than serving as an absolute contraindication in every case.

Open Debridement Arthroplasty

Open debridement arthroplasty is especially useful in younger, active patients with symptomatic impingement and stiffness but reasonably preserved articular surfaces.

The procedure may include capsular release, osteophyte removal, and excision of loose bodies.

Interposition Arthroplasty

Interposition arthroplasty may be considered in younger patients with severe joint destruction due to inflammatory or post-traumatic arthritis when total elbow arthroplasty is undesirable.

A biological or synthetic interposition material is placed between the damaged joint surfaces.

Advantages of Interposition Arthroplasty

Unlike total elbow arthroplasty, interposition arthroplasty does not impose the same strict lifelong lifting limitations.

This can make it attractive in selected younger patients.

Limitations

The procedure is generally unsuitable for elbows with substantial fixed coronal-plane deformity, historically more than approximately 10° of fixed varus or valgus.

A major complication is postoperative instability.

Radiocapitellar Hemiarthroplasty

Radiocapitellar hemiarthroplasty may be considered when arthritis is predominantly confined to the radiocapitellar articulation, particularly after trauma or in selected cases of primary osteoarthritis.

Total Elbow Arthroplasty

Indications

Total elbow arthroplasty is considered for patients with severe pain throughout the range of motion, substantial stiffness or loss of function, advanced joint destruction, and failure of nonoperative treatment.

Patient Selection

Because the implant has limited tolerance for repetitive heavy loading, total elbow arthroplasty is best suited to older, lower-demand patients who can comply with permanent lifting restrictions.

Contraindications

Relative or absolute contraindications include poor surrounding skin or soft tissue, uncontrolled infection, major neurologic impairment affecting the limb, and inability or unwillingness to comply with postoperative activity restrictions.

Follow-Up

Rheumatoid Arthritis

Patients with rheumatoid involvement of the elbow may be followed approximately every 6–12 months, depending on symptoms and systemic disease activity.

AP and lateral radiographs can be used to monitor progressive joint destruction.

Complications

Complications of Progressive Untreated Disease

Persistent severe arthritis may lead to ankylosis, progressive deformity, and ulnar nerve palsy or neuropathy.

Total Elbow Arthroplasty Complications

Potential complications after total elbow arthroplasty include infection, ulnar nerve irritation or injury, implant wear, and aseptic loosening.

Instability

Instability may occur after procedures such as interposition arthroplasty or in advanced inflammatory disease with ligamentous destruction.

Stiffness

Residual or recurrent stiffness can occur even after debridement or capsular release, particularly in patients with extensive scarring or advanced arthritis.

Patient Monitoring

Patients should be monitored for pain, progressive loss of motion, contracture, mechanical symptoms, instability, ulnar neuropathy, and radiographic progression.

After surgery, surveillance should additionally assess wound healing, range of motion, implant integrity when applicable, and recurrence of symptoms.