Osteoarthritis of the elbow

The pathophysiology of osteoarthritis includes several features: osteophytosis (formation of bony outgrowths or spurs) is a common finding, capsular contracture (tightening and stiffening of the joint capsule) may contribute to reduced joint mobility, loose bodies (fragments of cartilage or bone) may be present in the joint space, and periarticular osteophytes may impede normal joint movement. Osteoarthritis of the humero-radial joint is more frequent, while the humero-ulnar joint is often spared or less affected.

Post-traumatic arthritis is the second most common cause. It often occurs after conservatively treated radial head fractures, elbow dislocations and traumatic instabilities. Compared to other etiologies such as inflammatory and primary arthritis, it is more frequently observed in younger patients. It involves direct damage to the articular cartilage, creating incongruity and altering load distribution on the bearing surface of the joint. It may affect the whole joint, or be isolated to specific areas of the humero-radial and/or humero-ulnar joint. Patients with post-traumatic arthritis may experience symptoms such as stiffness, chronic instability, callus (poor fracture healing) or pseudarthrosis (failure to heal).

Inflammatory arthritis encompasses several conditions, rheumatoid arthritis being the most common in adults. Rheumatoid arthritis is also the most common form of arthritis affecting the elbow, with the elbow affected in around 20-50% of cases. Other causes of inflammatory arthritis affecting the elbow include psoriatic arthritis, systemic lupus erythematosus and pigmented villonodular synovitis. Its pathophysiology involves inflammation, chronic synovitis (inflammation of the synovial membrane), ligament damage, periarticular osteopenia (loss of bone density around the joint) and capsular contracture (tightening and stiffening of the joint capsule). It is characterized by fixed flexion contracture (permanent flexion of the joint), instability, ulnar or radial neuropathy (nerve compression), articular cartilage erosion, cyst formation, joint deformity, loss of joint space and progressive instability. These factors contribute to pain and functional limitations.

Osteoarthritis of the elbow usually presents with progressive pain, often felt at the end of range of motion rather than at mid-amplitude. Patients may also present with loss of maximum extension, sometimes with painful locking of the elbow. Unlike other joint conditions, nocturnal pain is unusual. On physical examination, loss of joint amplitude, particularly in maximal extension, may be observed, while forearm rotation tends to be relatively preserved in the early stages. Ulnar neuropathy may be present in up to 50% of patients.

Inflammatory arthritis of the elbow often follows damage to the hand and wrist joints. Symptoms include pain and loss of movement in the elbow. Physical examination may reveal fixed flexion contracture, where the elbow is constantly flexed, ligamentous incompetence, and sometimes ulnar neuropathy. It is important to evaluate the cervical spine in all rheumatoid arthritis patients affecting the elbow to assess any potential involvement.

The most commonly used imaging modalities are X-rays and CT scans. For rheumatoid arthritis patients undergoing surgery, cervical X-rays are also recommended. X-rays can reveal several signs, such as narrowing of the joint space indicating degeneration; the humero-ulnar joint space is often relatively preserved compared to other areas. Osteophytes (bony outgrowths) can be found in various places, as can loose bodies (fragments of cartilage or bone), which may be underestimated on plain radiography. In rheumatoid arthritis, periarticular erosions and cystic changes may be observed. CT scanning can be useful for surgical planning, as it provides more detailed images and can help to better define osteophytes and loose bodies.

Non-operative treatment is recommended for patients with mild to moderate symptoms, and is generally preferred before considering surgical management. It includes the use of non-steroidal anti-inflammatory drugs (NSAIDs), cortisone injections, rest splints and activity modification. NSAIDs can help reduce pain and inflammation in the joint. Cortisone injections can provide temporary relief by directly targeting inflammation in the joint. Resting splints can be used to immobilize the joint and reduce stress on the affected area. Activity modification involves modifying daily activities or work tasks to avoid aggravating symptoms and promote healing.

One of the techniques used is arthroscopic debridement combined with capsular release. Arthroscopic debridement allows the removal of osteophytes and loose bodies. This technique is recommended for patients with mechanical symptoms such as locking caused by loose fragments in the joint. It is also effective in treating stiffness due to capsular contracture or bone blockage. This surgical approach is preferred in patients with more than 90 degrees of elbow movement. However, there are some contraindications to consider, notably patients who have already undergone ulnar nerve transposition, and those with severe contracture or arthrofibrosis (excessive scar tissue formation in the joint). It is important to note that this technique can lead to potential complications, such as neurological damage, most often to the ulnar nerve, synovial fistula (abnormal communication between the joint and surrounding tissues) and a risk of recurrence of stiffness following the procedure.

Humero-ulnar interposition arthroplasty is indicated for younger, more demanding patients with end-stage arthritis. Unlike total elbow arthroplasty, which is indicated for older patients, this procedure has the advantage of requiring no weight restrictions. However, it is contraindicated in cases of elbow instability. The technique involves using either a tensor fascia lata autograft or an Achilles tendon allograft as an interposition spacer between the ulna and humerus to recreate the joint space. This helps to relieve pain and improve joint function. Patients whose preoperative movements were severely limited (maximum extension of more than 60 degrees and flexion of less than 100 degrees) are at risk of ulnar nerve dysfunction postoperatively, so a concomitant procedure involving decompression or transposition of the ulnar nerve is recommended.

Olecranon fossa debridement, also known as the Outerbridge-Kashiwagi procedure, is indicated for younger patients with decreased range of motion. This procedure involves creating a hole through the olecranon fossa and then removing osteophytes and arthritic bone. By removing these structures, the procedure increases the elbow’s range of motion. However, it is important to note that if there is a fixed flexion contracture, the ulnar nerve must be decompressed during the operation to avoid any nerve-related complications. It should be noted that this technique cannot treat anterior osteophytes (located on the front of the joint) or peripheral osteophytes on the medial and lateral aspects of the olecranon. This may limit the success of the procedure and have an impact on overall results.

Medial or lateral open capsular release combined with bone resection is a surgical procedure indicated for patients with extrinsic elbow contracture resulting in functional loss of extension and/or flexion. This procedure is commonly performed and involves releasing the tightened joint capsule and removing osteophytes to restore joint mobility. The choice of whether to perform a medial or lateral approach depends on the patient’s requirements. The medial approach is typically chosen when there is a need to gain flexion by excising the posterior band of the medial collateral ligament. The lateral approach may be chosen for patients who require restoration of extension or who have posterior bony impingement.

Total elbow arthroplasty is indicated for patients over 65 suffering from severe arthritis or post-traumatic arthritis. It is also indicated for elderly patients with poor bone quality, in cases of complex fractures, pseudarthrosis or malunion of the distal humerus. However, there are a number of contraindications to be taken into account, notably very active patients under 65, the presence of active infection and Charcot joint. This surgical technique has a high potential for complications, with rates as high as 43%. Infection is a major concern, as it can lead to implant failure and the need for further intervention. Instability of the elbow joint may occur, compromising the functional outcome of surgery. Loosening of the prosthesis is another complication that may require repeat surgery. Triceps insufficiency, which can affect elbow extension strength, is a potential complication that can impact overall function. Ulnar neuropathy is another potential complication that can lead to sensory and motor deficits.

Several risk factors that may increase the likelihood of complications have been identified, including patients with previous elbow surgery, patients with infections in the past (particularly caused by S. epidermidis), psychiatric comorbidities, rheumatoid arthritis, wound drainage, re-operation for any reason, and poor skin quality (e.g. due to long-term steroid use).

Two-stage revision arthroplasty, a procedure used to treat deep infections of total elbow prostheses, has been associated with poor survival rates. Injury to the ulnar nerve, which runs along the inside of the elbow, can occur during surgery and lead to sensory and motor deficits. Another potential complication is triceps avulsion, where the tendon connecting the triceps muscle to the bone becomes detached. Aseptic loosening, where the prosthesis loosens without infection, is a complication that may require revision surgery. Mechanical failure of the implant is a potential complication that may result from factors such as implant design or manufacturing defects. To mitigate the risk of complications, careful patient selection, thorough preoperative evaluation and adherence to surgical techniques are essential. In addition, patient education, appropriate post-operative care and regular follow-up visits are important to monitor and manage any potential complications that may arise.