Helping Surgeons Keep Abreast of Latest Information about Elbow Arthritis

The Accreditation Council for Continuing Medical Education (ACCME) has approved this article on elbow arthritis as a continuing education course for orthopedic surgeons. Anyone who reads the material and answers the questions correctly can earn two continuing education credits. In the process, the reader will gain an understanding of current thinking and orthopedic practice in the treatment of elbow arthritis.

Of course, anyone can read this review of current concepts related to elbow arthritis to keep up-to-date without taking the test or applying for the credits. The review is broken down into two major sections: diagnosis and management.

Recent developments in the treatment of elbow arthritis are the main focus of the review. Learning objectives include understanding function of the elbow and forearm, causes of elbow arthritis, types of patients who have this condition, and treatment (nonsurgical and surgical) of the problem.

As with all medical conditions, the diagnosis of elbow arthritis requires a careful patient history and clinical examination. Special tests (neurologic exam, examination of alignment, blood work) and imaging (X-rays, CT scans, or MRIs) are part of the evaluation process. X-rays are usually enough to identify joint damage, loss of joint space, and the presence of bone spurs or any "loose bodies" (fragments of bone or cartilage) inside the joint. More advanced imaging such as CT scans or MRIs are more likely ordered when surgery is being planned.

The physician must differentiate between rheumatoid (inflammatory) arthritis and osteoarthritis (degenerative disease). Recognizing differences in the signs and symptoms and patient history/patient type is important in making this distinction. For example, someone with rheumatoid arthritis of the elbow will have pain and stiffness throughout the full elbow range-of-motion.

A patient with osteoarthritis is more likely to have difficulty at the point of full elbow flexion or elbow extension. Pain through the entire range of elbow motion doesn't develop with osteoarthritis until the condition is very severe (considered "advanced" disease).

The patient's history can be very telling. Trauma to the elbow or a history of heavy use of the arm (e.g., weight lifting, construction work, throwing athletes) is linked with osteoarthritis. Patients with rheumatoid arthritis (RA) may have a family history of RA but no history of overuse to suggest osteoarthritis (OA).

The plan of care for anyone with elbow arthritis is to relieve pain and improve or restore function for daily activities. That sounds simple enough but there are many ways to approach this. The first is always with conservative (nonoperative) care. This can include medications, rest, physical therapy, and modification of activities. Treatment of osteoarthritis in manual laborers can be more challenging as they are unable to stop working or even change the way they use the arm because of the job requirements.

In the case of rheumatoid arthritis (RA), 10 per cent of patients will get full recovery with early diagnosis and aggressive treatment with disease modifying anti-rheumatic drugs (DMARDs) and other biologic therapies. Surgery for elbow arthritis is only recommended when patients fail to improve with nonsurgical care. Surgical options include synovectomy, arthroscopic debridement, and joint replacement (called arthroplasty).

The choice of which surgical procedure to perform depends on whether the condition is inflammatory (rheumatoid) arthritis or degenerative (osteoarthritis). Other considerations include type of work (use or physical demands placed on the elbow), severity of the arthritis, and the age of the patient.

This continuing education review includes a detailed section on each surgical treatment option -- how to perform the procedure, when to use it, and what to expect in terms of outcomes or results. It is readily recognized that treatment is different for each person. Patient expectations are important to consider.

And surgeons must take into consideration illness behavior that often accompany disability from elbow pain, stiffness, and loss of motion and function. Illness behavior describes patients who are afraid to use the arm because of the pain, individuals seeking secondary gain from job-related injuries, and a concept known as catastrophizing. Catastrophizing refers to patients who blow the symptoms and losses (motion, function) out of proportion or who see the situation from a negative view (what they cannot do rather than what they can do).

One final note about this review and continuing education tool: the material is not intended to represent the only methods or best procedures for elbow arthritis. Rather, it provides a helpful review of current approaches used successfully by many orthopedic surgeons. The final exam consists of two questions. The answers are easily found in the text.

References: Loukia K. Papatheodorou, MD, PhD, et al. Elbow Arthritis: Current Concepts. In The Journal of Hand Surgery. March 2013. Vol. 38A. No. 3. Pp. 605-613.