5.5 Osteoarthritis of the elbow joint

Osteoarthritis is defined as a ‘non-inflammatory disorder of movable joints characterized by deterioration and abrasion of articular cartilage with formation of new bone at the joint surfaces’. Involvement of the elbow with this condition was once thought to be rare, although more recently its prevalence has been shown to be more common.

The prevalence of symptomatic primary osteoarthritis of the elbow is around 2% and occurs most frequently in men involved in heavy manual labour. An increased incidence of osteoarthritis of the elbow in the dominant arms of middle-aged men in association with arthritis of the hip, knee, and metacarpophalangeal joints has been reported.

The use of pneumatic drills as an aetiological factor in the development of elbow osteoarthritis has been debated for a long time. However, a study has failed to show a direct relationship between the use of this type of equipment and the development of the condition.

Primary arthritis of the elbow has been shown to begin at the radiocapitellar joint as part of the normal ageing process with later involvement of the ulnohumeral articulation. It has been postulated that this may be due to the radiocapitellar joint performing a combined rotation and hinge movement as compared to the purely hinge motion in the ulnohumeral articulation. It is known that forces up to three times the body weight cross the elbow joint during strenuous lifting and up to six times during dynamic loading such as throwing or pounding.

The most common cause of secondary osteoarthritis of the elbow is trauma. Intra-articular fractures of the distal humerus and radial head fractures can lead to the development of osteoarthritis. Management of this group of patients can be difficult due to loss of bone stock, presence of deformities, and previous surgeries.

Other causes of secondary arthritis of the elbow include: infection, bleeding disorders, and neuropathic pathologies.

Infection within the joint will result in destruction of the articular cartilage and should be treated with prompt washout and appropriate antibiotic therapy.

The commonest cause of haematologic arthritis is haemophilia. Recurrent bleeds with haemosiderin deposition and release of proteolytic enzymes results in destruction of the articular cartilage. Chronic arthropathy in the early stages can be managed well with a specifically designed regimen of exercises to maintain a functional range of elbow motion. In the later stages, synovectomy and total elbow replacement remains the mainstay of treatment.

Neuropathic arthritis predominantly occurs as a result of syringomyelia, tabes dorsalis, diabetes mellitus, congenital indifference to pain, and surgical denervation. The joint is subjected to repeated traumatic episodes not recognized by the patient due to loss of protective joint nociception and proprioception resulting in formation of a Charcot joint. As pain is rare, surgery is rarely considered and protective splinting remains the mainstay of treatment.

Although secondary osteoarthritis can occur in either sex and at any age, primary osteoarthritis is predominantly seen in men rather than women by a ratio of 4:1. The disease usually presents in the fifth decade of life with the dominant extremity most commonly involved. The symptoms and signs include:

Plain anteroposterior and lateral radiographs are usually sufficient to make the diagnosis and no other investigations are normally required. Radiographs typically show osteophytes at the tip of olecranon and coronoid processes. The olecranon and coronoid fossae also reveal ossification and osteophytes. There is reduction in the joint space and loose bodies are often present (Figure 5.5.1). Recently a radiographic classification system for primary osteoarthritis of the elbow has been proposed. Rettig and colleagues also propose that this classification system has validity in predicting postoperative outcomes.

Occasionally a computed tomography scan can be useful in locating loose bodies or delineating the extent of osteophytes prior to surgical planning.

Nerve conduction studies should be performed in cases of ulnar neuritis.

Symptoms in the early stages of arthritis can be controlled by lifestyle modifications, analgesics, and anti-inflammatory medication (Box 5.5.3). Although intra-articular steroids have been shown to be of some symptomatic relief, they are rarely used in practice due to their short-term benefits.

Splinting and physiotherapy are of use in post-traumatic elbows but are of little value once the degenerative process becomes established.

Viscosupplementation has been used to treat arthritic conditions around the knee and, more recently, the elbow. A study by Van Brakel and Eygendaal involved giving a series of three injections of sodium hyaluronate within a 4-week period for treatment of post-traumatic arthrosis of the elbow. It was seen to provide slight, short-term pain relief but no benefit was observed after 6 months. The authors did not recommend this treatment for post-traumatic arthritis of the elbow.

A number of surgical options are available for the treatment of elbow arthritis (Box 5.5.4) which can broadly be divided into arthroscopic and open procedures. The exact choice of procedure depends upon the patient’s symptoms, the radiological evaluation, and the surgical expertise.

The elbow is the most congruous joint in the body. Degenerative changes further reduce the intra-articular space making instrument manipulation more difficult. This in association with the close proximity of the major neurovascular structures makes elbow arthroscopy a technically demanding procedure with a steep learning curve. Surgeon experience and familiarity with elbow arthroscopy is essential in preventing complications during arthroscopic debridement.

Originally elbow arthroscopy was used for the removal of loose bodies but later it was also appreciated that osteophytes could also be excised. Recent studies have established elbow arthroscopy as an important tool in performing debridement, osteophyte and loose body removal, and capsular releases. Adams and colleagues described the results in 42 primary osteoarthritic elbows treated by arthroscopic osteophyte resection and capsulectomy with a minimum of 2 years’ follow-up. They had 81% good to excellent results with minimal complications. However, like other studies, this review does not establish that an arthroscopic procedure is superior to open debridement, has improved outcomes, or results in earlier return to function. Additionally, radial head excisions can also be performed successfully arthroscopically, especially in post-traumatic arthrosis. Radial head excision is not often required in primary degenerative arthritis unless the patient experiences predominantly lateral-sided pain or has significant pain on forearm rotation.

These procedures are useful when conservative measures fail to provide adequate symptomatic relief.

Kashiwagi described a joint debridement procedure which he attributed to Outerbridge and called the Outerbridge–Kashiwagi or OK procedure. This is a simple technique allowing the removal of loose bodies and excision of osteophytes. It is performed using a posterior surgical approach. If indicated, the ulnar nerve can also be decompressed at the same time.

Technique of OK procedure: the procedure can be undertaken either in a supine position with a sandbag under the scapula or in a lateral decubitus position with the arm supported by a bolster. Under tourniquet control, a midline central incision is made over the posterior aspect of the elbow joint approximately 8cm above the tip of the olecranon. The triceps is split in the line of its fibres and the posterior capsule of the joint is exposed. The capsule is incised and any loose bodies in the posterior compartment removed. Osteophytes around the tip of the olecranon are excised. A bone burr is then used to fenestrate the floor of the olecranon fossa providing an opening into the anterior compartment of the elbow. Loose bodies from the anterior compartment are identified and removed at the fenestration by flexing and extending the elbow. The tip of the coronoid process is then brought into view by flexing the elbow and coronoid osteophytes removed using a fine osteotome. Osteophytes around the coronoid fossa can be removed using a Kerrison rongeur. This also partially releases the anterior capsule. The finger can then be passed through the fenestration to confirm the adequacy of resection (Figure 5.5.2). The joint is then thoroughly lavaged and closed in layers over a suction drain. The drain is removed at 24 hours and mobilization commenced with the help of therapists.

The OK procedure was modified by Morrey (1992) and termed the ulnohumeral arthroplasty (UHA). Morrey elevates the medial half of the triceps rather than performing a triceps split. He believes this causes less blood loss and less swelling. He also uses a bone trephine to create the fenestration into the anterior compartment rather than a burr since he feels that this provides a more predictable and cleaner resection and creates less bone debris. The placement of the trephine is vital so as not to compromise the integrity of the trochlea, capitellum, or lateral and medial columns. Morrey also uses a more aggressive postoperative regimen. This involves the use of a brachial plexus block with a catheter for 2–3 days together with continuous passive motion and the use of splints to maximize the operative gain.

Results: Minami and Ishii (1986) presented their initial results showing good pain reduction and improvement in motion. Their subsequent study showed some deterioration of the results with time. Recurrence of symptoms was seen in 20% of cases at 10 years and recurrence of radiographic changes in up to 50% at 5 years. Morrey’s study (1992) highlighted similar conclusions.

Several other studies have shown good mid- to long-term results of open UHA confirming its durability as a good procedure for this condition. Antuna et al. (2002) reported good or excellent results in 34 of 46 patients at an average of 80 months after surgery. To avoid postoperative ulnar nerve complications, they recommended decompression or mobilization of the nerve in patients who had preoperative flexion of less than 100 degrees, where a flexion gain of more than 30–40 degrees was expected or in patients who had preoperative ulnar nerve symptoms. Wada et al. (2004) reported satisfactory results in 85% of patients at an average of 121 months after surgery. They also found that 76% of their patients returned to preoperative strenuous labour after surgery. None of the elbows in these discussed studies converted to total elbow replacement in spite of the follow-up being up to 13 years in some cases.

Tsuge and Mizuseki (1994) advocated a more extensive surgical procedure especially in young patients with more aggressive disease. The procedure involved isolation and protection of the ulnar nerve followed by reflection of the extensor mechanism medially. The radial collateral ligament together with the posterior portion of the medial collateral ligament was then divided and the joint dislocated. Loose bodies were removed, the capsule released, and all osteophytes around the olecranon and coronoid excised. The olecranon and coronoid fossa were then deepened and, if required, the radial head reshaped. Continuous passive motion was then continued for 7 days postoperatively. The authors reported reduced pain and improved motion in most of 29 of their cases at a mean of 64 months.

Some patients with osteoarthritis of the elbow present predominantly with symptoms of loss of motion. They develop progressive loss of extension with a reasonably pain-free mid arc of motion. This confirms a predominantly extrinsic contracture involving periarticular capsule ligamentous structures. The column procedure is useful in such patients in order to gain a functional range of motion especially if the extension deficit exceeds 20 degrees. The procedure involves a lateral Kocher incision with elevation of the brachioradialis and extensor carpi radialis brevis in order to gain exposure to the anterior aspect of the joint. The anterior capsule is then excised with removal of loose bodies and ostephytes. The triceps is then elevated to gain access to the posterior aspect of the joint and a similar procedure is repeated posteriorly. Continuous passive motion is instituted postoperatively to maintain the surgical gain. The Mayo clinic experience showed excellent pain relief and a substantial gain in range of motion following this procedure in spite of an heterogenous group of pathologies.

This technique involves reshaping of the distal humerus and proximal ulna, interposition of a membrane between the elbow joint surfaces, and suturing it to the humeral side. Skin, fascia, and Achilles tendon allograft are most commonly used as interposition tissue. Collateral ligaments are either repaired primarily or reconstructed. A unilateral hinged fixator keeps the joint slightly distracted and allows early active range of motion. The procedure is suitable in young patients (under 60 years old) suffering from incapacitating pain due to traumatic or primary degenerative arthritis affecting the elbow and who have failed to respond to joint debridement procedures. Recent sepsis, an unfused epiphysis, and grossly unstable elbows are contraindications for this procedure. The technique also does not guarantee enough stability for heavy manual work. Larson and Morrey in 2008 updated the Mayo experience of 69 consecutive elbows that underwent interposition arthroplasties using achilles tendon allgraft and a hinged fixator. Three fourths of the patients suffered from post-traumatic arthritis. They concluded that this is a good salvage procedure for young active patients with severe inflammatory or post-traumatic arthritis, especially with limited elbow motion. They emphasized to exercise caution when using this procedure in patients with instability or severe pain.

The indications for total elbow replacement are constantly evolving. It is an established and effective treatment in patients with inflammatory arthritis but its role in young patients suffering from primary degenerative arthritis is still limited. It is particularly unsuitable in patients planning to undertake manual work after replacement surgery. It is recommended that after total elbow replacements patients do not lift more than 4–5 kg with the operated arm as a single event or more than 1 kg repeatedly. Currently, total elbow arthroplasty is only indicated in patients with primary osteoarthritis of the elbow who are older than 65 years of age, are retired, have low activity levels, experience pain throughout the range of motion, or who have substantial deficits in motion in whom all other interventions have failed. In addition the patients must be happy to comply with postoperative restrictions which are essential after such a procedure.

Espag et al treated 10 patients with primary osteoarthritis of the elbow using an unlinked total elbow replacement. At a mean of 68 months after surgery, one had loosened and needed revising and a further two showed radiographic signs of loosening but 9 out of 10 were satisfied with the procedure.

Osteoarthritis of the elbow is a common condition. Patients present with symptoms of pain and stiffness and occasionally complain of locking due to the presence of loose bodies. Ulnar nerve symptoms may also coexist. X-rays are usually diagnostic and often no other investigations are required.

Conservative treatment is a good option in the early stages but surgical treatment may become necessary. Arthroscopic and open procedures are both effective in removal of loose bodies, capsulectomy, and osteophyte excision. The choice of procedure depends upon the patient symptoms, radiological appearances, and surgical expertise.

Interposition arthroplasty is only rarely performed. Total elbow replacement is also rarely indicated in this group of patients as they are often young and involved in manual work.