Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Elbow Arthritis

Basics
Description
  • The elbow can be affected by inflammatory and noninflammatory arthropathies.
  • Regardless of the underlying pathologic process, elbow arthritis generally presents with pain on ROM and loading of the affected joint.
Epidemiology
Incidence
  • Uncommon
  • Primary osteoarthritis accounts for 1-2% of all elbow arthritis; the remainder are inflammatory or posttraumatic.
  • Can occur in any age group
  • Males and females are affected equally.
  • Most authorities recommend reserving total elbow arthroplasty for patients >60 years old.
Risk Factors
  • Rheumatoid arthritis
  • History of septic arthritis
  • Previous injury
Etiology
  • Inflammatory arthropathies
  • Trauma
Diagnosis
Signs and Symptoms
  • Degenerative joint disease of the elbow presents as pain at the extremes of motion that is generally greater in extension than in flexion.
    • A history of trauma often is present.
      • Carrying an object, such as a briefcase or groceries, is possible only for short periods.
    • In later stages, pain can be present with reduced ROM, and a flexion contracture may develop.
    • AP and lateral radiographs show osteophyte formation and bony sclerosis of the elbow.
  • Inflammatory arthropathy can present with a similar pain profile.
    • Patients also have signs of inflammation, such as effusion and warmth.
    • Early in the disease, radiographs may be normal because only intense synovitis and effusion are present.
Physical Exam
  • Pain and limited ROM are the earliest findings.
  • Effusions are palpated most easily on the lateral side of the elbow.
  • Contractures may be seen.
  • Ulnar neuropathy can be seen in late presentations.
  • Ankylosis of the elbow develops with advanced disease.
Tests
Lab
  • Rheumatologic workup is indicated if an inflammatory arthropathy is suspected.
  • Joint aspiration with cell count and differential is warranted if a septic joint is a concern.
  • Joint fluid may be sent for crystal analysis if crystalline arthropathy is suspected.
Imaging
Routine AP and lateral radiographs of the elbow
  
Pathological Findings
  • With rheumatoid arthritis, the synovium proliferates and progressive destruction of the joint occurs.
  • The radial head often is destroyed, and valgus deformity occurs.
Differential Diagnosis
  • Septic joint
  • Elbow instability
  • Tendinitis
  • Nerve entrapment syndromes
Treatment
General Measures
  • Operative treatment should be reserved for those patients for whom nonoperative measures have failed and who continue to have debilitating pain.
  • Activity should be modified to suit the level of symptoms.
Special Therapy
Radiotherapy
  • Radioactive synovectomy:
    • Via sterile intra-articular injection of a radioisotope
Physical Therapy
  • Strengthening and ROM exercises are helpful for patients who respond to nonoperative management.
  • A similar postoperative physical therapy regimen is critical to obtaining the highest level of functioning possible after arthroplasty or elbow replacement.
Medication (Drugs)
  • Initial management should be nonoperative, with NSAIDs, rest, and bracing or supportive devices.
  • In addition to NSAIDs, antimalarial agents, gold salts, immunosuppressive drugs, and corticosteroids are used.
  • Caution should be used with bracing and immobilization of the elbow because elbow stiffness and even ankylosis may occur quickly.
  • Patients who are unresponsive to systemic anti-inflammatory drugs may benefit from intra-articular steroid injections.
    • Care must be exercised with this treatment option because improper aseptic technique can result in joint infection.
    • Frequent injections can weaken tendinous and ligamentous structures.
Surgery
  • A variety of surgical options are possible, depending on presentation:
    • Arthroscopy represents an early surgical option for elbow arthritis; in addition to an arthroscopic synovectomy for pain relief, osteophytes can be excised to improve ROM.
    • Osteotomy (Outerbridge-Kashiwagi arthroplasty, an excision of olecranon and coronoid osteophytes) for decompression in an area of impingement in osteoarthritis
    • Interpositional arthroplasty in patients <60 years old with posttraumatic arthritis
    • Total elbow arthroplasty for:
      • Patients for whom nonoperative interventions have failed
      • Patients undergoing less invasive surgical treatments or who have osteoarthrosis involving more than the ulnohumeral joint
    • Resection arthroplasty for salvage (i.e., cases of failed total elbow arthroplasty)
    • Arthrodesis may be considered for intractable sepsis or when revision arthroplasty is not possible.
  • Ulnar nerve decompression is indicated in all of the above if evidence of nerve irritation is present.
Follow-up
Complications
  • Nonoperative treatment:
    • Ankylosis
    • Ulnar nerve palsy
  • Total elbow arthroplasty:
    • Infection
    • Ulnar nerve irritation
    • Aseptic loosening
Patient Monitoring
Patients with rheumatoid arthritis are followed at 6-12-month intervals with AP and lateral radiographs.
 
Miscellaneous
Codes
ICD9-CM
716.92 Elbow arthritis
 
Patient Teaching
Activity
Patients are shown how to avoid aggravating activities and are encouraged to maintain a functional ROM.
 
FAQ
Q: Does arthroscopy have any role in the treatment of elbow arthritis?
A: Arthroscopy provides a minimally invasive way of performing a synovectomy to reduce pain and swelling and to improve the ROM. It also allows for early physical therapy.

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