Elbow Arthritis

By admin On Jan 17, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > Elbow Arthritis

Elbow Arthritis

Jinsong Wang MD

Mark Clough MD

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 (1).
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.

P.113

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 (2).
- Osteotomy (Outerbridge-Kashiwagi
  arthroplasty, an excision of olecranon and coronoid osteophytes) for
  decompression in an area of impingement in osteoarthritis (3)
- Interpositional arthroplasty in patients <60 years old with posttraumatic arthritis (4)
- Total elbow arthroplasty for (5):
  - 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.

References

1. Wada T, Isogai S, Ishii S, et al. Debridement arthroplasty for primary osteoarthritis of the elbow. J Bone Joint Surg 2004;86A:233–241.

2. Ramsey ML. Elbow arthroscopy: basic setup and treatment of arthritis. Instr Course Lect 2002;51:69–72.

3. O’Driscoll SW. Elbow arthritis: treatment options. J Am Acad Orthop Surg 1993;1:106–116.

4. Morrey BF. Nonreplacement reconstruction of the elbow joint. Instr Course Lect 2002;51:63–67.

5. Kozak TK, Adams RA, Morrey BF. Total elbow arthroplasty in primary osteoarthritis of the elbow. J Arthroplasty 1998;13:837–842.

Additional Reading

King GJ. New frontiers in elbow reconstruction: total elbow arthroplasty. Instr Course Lect 2002;51:43–51.

Yamaguchi K, Adams RA, Morrey BF. Infection after total elbow arthroplasty. J Bone Joint Surg Am 1998;80:481–491.

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.