Elbow arthritis

Arthritis encompasses a group of conditions that lead to damage to the joint surfaces.

There are several different kinds and causes of arthritis.

The most common being:

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Osteoarthritis - Often referred to as wear and tear arthritis (althoughthis is probably a little simplistic)

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Rheumatoid arthritis - A generalised inflammatory condition that mayaffect many and any joint,

leading to joint destruction.

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Post traumatic arthritis - If the joint surface is damaged and not smooth,with time the joint may wear

out, also referred to as secondary osteoarthritis.

Each underlying cause for the arthritis needs to be treated based on its own merits.

The final end point when the joint is worn out  has very similar treatment options

General principles

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Relative rest (Joints that keep moving do better than those that don't, doing nothing is as bad as doing too much, absolute rest is bad)

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Activity modification (avoid activities that over stress the joint)

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Pain killers (including NSAID's)

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Physiotherapy

 Surgical options

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Release of contractures and debridement of elbow - OK procedure, ulnohumeral arthroplasty, radial head excision, column procedure

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Interposition arthroplasty

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Arthrodesis

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Total elbow replacement (prosthetic joint)

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Partial elbow replacement (prosthetic joint)

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Excision arthroplasty

 Release of contractures and debridement of elbow

 In the early stages of arthritis of the elbow, in relatively young patients and patients who want to still undertake heavy/ manual work.

 The joint replacement options are not good solutions for various reasons. (see below).

 Part of the disease process in arthritis is the development of loose bodies (these are loose fragments of bone and cartilage that may jam/ lock up the

elbow), the body also grows osteophytes, osteophytes are little bone spurs that stiffen the joint.

 Loose bodies and osteophytes may lead to the elbow locking up and becoming stiff and painful.

 Depending on the size, position and number of the osteophytes and loose bodies it is possible to remove them.

This may be done with open surgery or arthroscopically (keyhole surgery).

Several options exist depending on the predominant problem.

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Arthroscopic capsular release, washout and removal of osteophytes

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Radial head excision - If the arthritis is predominantly on the outer side of the elbow, it is possible to remove the radial head and improve the

pain.

 I would normally do this arthroscopically.

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O-K procedure (Outerbridge-Kashiwagi) procedure - This can be done as an open procedure or arthroscopically and in essence removes all

those osteophytes that form with time

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Ulno humeral arthroplasty - Very similar to the OK procedure, release of contractures and removal of loose bodies and osteophytes.

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Column procedure - This is an open procedure. It involves release of contractures and removal of osteophytes, particularly useful if lack of

extension is from thickening of the capsule in the front of the elbow.

 Interposition arthroplasty

 Interposition arthroplasty is not a great solution to the stiff painful arthritic elbow, but may be the lesser of several evils.

 Particularly in the relatively young patient who wants movement, elbow stability and some degree of durability.

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Elbow arthrodesis (fusion) (see below) - Once the elbow is fused pain is improved and function improved by providing a durable stable solid

joint. However it will never bend or straighten again.

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Elbow prosthetic joint replacement - Provides good pain relief and good function BUT as with all mechanical joints is subject to failure and will

in essence wear out. Patients are in essence restricted to no more than 0.5 Kg repetitive lifts and around 2.5 Kg single lift.

 The painful arthritic joint surfaces are removed and the joint lined with a biological material.

 Several biological materials have been tried.

 The outcome following interposition arthroplasty can be pretty variable.

 The main complications apart from the general complications of any surgery are instability.

 The elbow joint may dislocate or simply give way when trying to use it.

 Although the bearing surface is biological an interposition arthroplasty does not last forever and in general will last around 8 years before it fails.

 Elbow arthrodesis

 It is possible to fuse the elbow (arthrodesis) so that it never moves again.

Elbow arthrodesis provides significant relief of pain in cases of destroyed elbows and improves function of the involved arm.

 This is particularly true in the young patient where the limitations of an artificial joint need to be avoided and where the unpredictability of an

interposition or excision arthroplasty need to be avoided.

 It provides a stable strong, durable joint to continue with heavy work for manual workers.

The elbow will no longer flex (bend) or extend (straighten), some degree of forearm rotation may persist.

There is no universal position to fuse the elbow in.

Most surgeons would suggest a position of 90-100º of flexion, this enables the most powerful grip-strength.

A fusion angle of 45º flexion may be  more useful in assisting daily activities in some non-dominant arms but personal hygiene and care cannot be

performed.

 More than 90% of volunteers rated several activities of daily-life as difficult to impossible when braced in 45º flexion.

 They found touching the back of their heads, mouth, opposite shoulder drinking from a glass or using a telephone as impossible, more than 80%

would choose 90º.

 The angle of fusion depends on several factors.

 In essence I would advise living in a cast with trial positions of fusion for a month or more to find the optimal fusion angle for you.

  Issues to consider:

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Whether working activities or self care are the main goal.

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Mobility of the other arm, of other joints including spine

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For patients with both elbow joints involved, it is best to try do a joint replacement or excision arthroplasty on at least one of the elbows

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If both elbows are to be fused , consider dominant elbow - greater than 90º (110-120º), non dominant elbow - less than 90º (40-65º)

 Total elbow replacement (prosthetic joint)

 Total joint replacement is well established for arthritis of the larger joints, hips, knees and shoulders.

 Elbow joint replacement is very good for pain relief and improving range of motion and function.

 In general elbow replacements are rated as excellent or good in 80% of patients.

 Range of motion is improved on average by 30º, although this is variable.

 The down side of elbow replacements is that the joint is very small and the forces transmitted across the elbow are magnified by the lever arms

across the elbow.

 Around one third of cases have some kind of complication.

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Infection - deep infection occurs in around 5 % of cases, this is higher than for other joint replacements (hips and knees around 1%).

 This is due to the fact that the artificial joint is just under the skin and any superficial wound infection or wound healing problems very quickly tracks

down to the joint.

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Wound healing problems - account for around 10%.

 The skin over the point of the elbow is very thin and healing may be impaired.

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Nerve injury - permanent nerve injury occurs in only 5% of cases, transient injury and tingling in the ulna nerve distribution (little and ring

fingers) occurs more commonly 20%.

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Implant failure - A mechanical joint once inserted has a finite life span, due to the delicate nature of the implants and significant forces across

the elbow.

 Following an elbow replacement you should use but not abuse your elbow. In essence you should limit yourself to 0.5 kg repetitive lift, and no more

than 2.5kg single lift.

 Bones and implants do not like torque (twisting forces, for example arm wrestling, or if you lift a heavy box pushing on the sides).

 If you do need to do heavy work or lifting try doing it in straight lines. Implant failure and loosening of the implant occurs in 10-15% of cases either

slight loosening of the implant or fracture of the metal stems.

 All told around 80% of elbow replacements are still functioning at 10 years.

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Periprosthetic fracture - fractures can occur at the time of insertion of the implant.

 Where the implant ends the stiff implant increases the stress on the bone and if a patient falls the bone usually fails around the implant.

Partial elbow replacement (prosthetic joint)

Depending on where the majority of the arthritis is it is possible on occasion to replace only part of the joint.

This is normally the outer side of the joint (lateral joint).

This may involve a hemiarthroplasty, eg radial head replacement or lateral resurfacing arthroplasty where both sides of the lateral side of the elbow

are replaced.

Excision arthroplasty of Elbow (total)

This is only very rarely undertaken.

 It is usually the last option if the procedures above have failed or to eradicate deep seated elbow infection.

In some cases it may be a temporary step to eradicate infection, followed by a fusion or total elbow replacement once the infection and soft tissues

have resolved.

 Excision arthroplasty involves removal of all the components of the elbow, including any metalwork that may be present. The space fills with scar

tissue which is pretty soft and floppy initially, but matures with time and some use of the arm remains.

It is not possible to do any heavy lifting or heavy work with the elbow as it leaves the arm slightly unstable.

For patients who need to support there body weight on crutches it is not a good solution

 It is important to note a simple radial head excision is a kind of excision arthroplasty of the elbow (see debridement above), the outcome and

complication are very different from a total elbow excision arthroplasty and often compatible with good pain relief and function.

References

Total elbow arthroplasty: A SYSTEMATIC REVIEW OF THE LITERATURE IN THE ENGLISH LANGUAGE UNTIL THE END OF 2003; C. P. Little, A. J. Graham,

and A. J. Carr; J Bone Joint Surg Br, Apr 2005; 87-B: 437 - 444.

The fate of elbow arthrodesis: Indications, techniques, and outcome in fourteen patients; Heiko Koller, Klaus Kolb, Allan Assuncao, Werner Kolb,

Ulrich Holz; Journal of Shoulder and Elbow Surgery; March 2008 (Vol. 17, Issue 2, Pages 293-306)