Update on Treatment of Elbow Arthritis

How do you know if that elbow stiffness, pain, and loss of motion you are having is arthritis? What causes elbow arthritis? What can be done about it? In this article, experts in the area of hand and upper extremity surgery review studies from the past five years and attempt to answer these questions.

The diagnosis of elbow symptoms begins with a patient history followed by a physical exam. The symptoms could be from rheumatoid arthritis, osteoarthritis, infection, or some other problem. By identifying the location of pain and the aggravating/relieving factors, doctors can help narrow down the underlying cause.

For example, rheumatoid arthritis usually causes pain throughout the entire range-of-motion. The pain is more likely to be located along the outside edge of the joint. Osteoarthritis is more common among males involved in heavy lifting (e.g., manual laborers, weight lifters, throwing athletes). Osteoarthritic pain is more likely to be present at the beginning and ending of motion, rather than throughout the entire arc of motion.

Examination by the physician takes into account any skin changes, joint motion (quantity and quality), and blood work. Lab studies examining the blood can identify the presence of infection as a possible source of pain and stiffness.

Sometimes the clinical exam is said to be unremarkable. That means there weren't enough findings to point to anything specific. Then X-rays or other more advanced imaging studies can be ordered. X-ray findings do help identify the difference between rheumatoid and osteoarthritis. The X-rays may show the presence of bone spurs, narrowing of the joint margins, and the presence of any fractures, subluxations, or dislocations.

Once the diagnosis has been made, the doctor turns his or her attention to developing a plan of care that will prevent further complications or problems. If it looks like surgery might be necessary, CT scan and/or MRIs may be ordered.

Treatment is divided into two types: conservative (nonoperative) and surgery. Nonsurgical treatment usually begins with medications to control symptoms and prevent damage to the joint. For some patients, the use of antiinflammatory drugs and disease modifying anti-rheumatic drugs (DMARDs) can completely eliminate all signs and symptoms of rheumatoid arthritis.

No matter what the cause of the problem is, activity modification, rest, and physical therapy are often recommended. Sometimes splinting is advised to help protect, support, and mobilize (move) the joint. If after three to six months of conservative care, there is no improvement (or the symptoms are worse), then surgery may be an option.

There are various types of surgical procedures to consider. Which one is selected depends on the patient's age, diagnosis, job demands, or sports participation. The selection of surgical procedures also takes into account the areas of the joint affected most (e.g., joint surface, capsule, synovium). The surgeon does everything possible to preserve the dynamic nature of the joint -- both stability and mobility needed for upper extremity function.

Sometimes, the surgeon can go into the joint using an arthroscope and thus avoid a more invasive open incision approach. It may be possible to remove bone spurs, loose fragments of bone or cartilage, or even release the joint capsule to reduce pain and improve elbow motion. This procedure is called arthroscopic débridement.

Studies show that this approach can be quite successful for patients who have not had major elbow trauma. A history of previous elbow injury would be a contraindication to arthroscopic surgery. In those cases, the surgeon must use an open incision approach. The reason for this is to avoid damaging nerves or blood vessels that have shifted from their normal anatomic position as a result of the previous injury.

Besides débridement, removing a portion of the bone called resection may be helpful. The head (top) of the radius (forearm bone) is resected when there is damage or disease of the radiocapitellar joint. This is where the radius joins the bottom of the humerus (upper arm bone) to form part of the elbow joint. This procedure is done when there is pain with forearm rotation.

More extensive surgery such as interposition arthroplasty or a total elbow replacement may be needed. Younger, more active patients with severe inflammatory arthritis benefit from the interposition arthroplasty.

This surgical technique shaves away the joint surface, removing any bone spurs and loose fragments of bone or cartilage in the joint. A piece of tendon used as a graft is placed where the surfaces of the elbow joint are rubbing together. The main goal of interposition surgery is to ease pain by using the soft tissue graft to form a spacer separating the surfaces of the joint. The patient can still lift more than the 10-pound lifting limit imposed on total elbow replacements.

Total elbow arthroplasty (replacement) is used for the older adult (65 years or older) who has severe pain and loss of motion and function. Conservative care has not been able to help. Patients with rheumatoid arthritis of the elbow seem to have the best results with this approach. They have to be willing to restrict activities that involve lifting more than 10 pounds.

Today's improved elbow implants do a better job of reproducing normal elbow motion than earlier designs. The newer prostheses allow for side-to-side and rotational motions needed for full elbow motion. Various implant systems are available now (e.g., constrained, unconstrained, convertible, fixed).

Each new generation of implant designs try to improve elbow stability while still allowing mobility at the same time preserving bone and soft tissue structures. Patients who have arthritis compounded by fractures and/or loss of bone mineral density may need one of these newer implants. Older adults seem to do better with elbow implants than younger patients. They have far fewer problems and are much less likely to need a second (or third) surgery.

Companies designing and making elbow implants continue to look for better materials that won't wear loosen, or break. Preventing mechanical failure of the implant will improve long-term results for patients with various kinds of elbow problems. There is still a need to find an implant that will hold up with active use for younger patients who have debilitating elbow arthritis.

References: Zinon T. Kokkalis, MD, et al. Elbow Arthritis: Current Concepts. In The Journal of Hand Surgery. April 2009. Vol. 34A. No. 4. Pp. 761-768.