Elbow Arthritis

What is elbow arthritis?

There are 2 main types of arthritis: Osteoarthritis; and Inflammatory arthritis.

Osteoarthritis is the common wear and tear arthritis seen with ageing. It can affect the elbow although not commonly.

Inflammatory arthritis includes conditions like rheumatoid arthritis. It is a systemic (body wide) problem where the body’s defence mechanisms attach their own joints. This will not be considered here but will be address in the section on rheumatoid arthritis (see information sheet).

Elbow osteoarthritis is either primary i.e. occurring for no obvious reason or secondary i.e. occurring due to an underlying cause. The most common cause of secondary arthritis is previous injury particularly a fracture (break) into the joint (intra-articular).

Patients typically present in later middle age (50+) with gradually increasing stiffness/pain. They main run together or one or other may predominate. Sometime the symptoms will come on quite quickly following a sudden injury which may be quite mild but then tips the elbow over from being potentially symptomatic to being symptomatic. The symptoms may increase giving marked disability due to restricted movement and pain both at night and in the day.

Why does it occur?

Normal joints are lined with articular cartilage and lubricated with a little bit of fluid that is continually renewed. Either due to general wear and tear, an inherited tendency or a structural abnormality in a joint such as a previous fracture (break) or operation the lining of the joint thins and may wear away leading to bone rudding on bone.This is not necessarily painful but may be. The cartilage that rubs off may float around in the joint creating little bodies like pearls in the joint known as loose bodies. These can catch between the bones giving sudden stiffness and pain known as true locking. More commonly the joint tries to protect itself by forming a little more new bone at the edges and producing more joint fluid. These lead to stiffness and deformity. These may in turn lead to other secondary problems such as nerve irritation. This is a particular problem at the elbow where the ulnar nerve runs close to the back of the inner side of the joint. This can lead to weakness and numbness in the ring and little fingers – ulnar neuritis (see information sheet).

What happens if nothing is done?

(This is referred to as the natural history i.e. what happens if Nature runs its own course.) Some people’s symptoms resolve enough to no longer be too intrusive especially if they can modify their activities. Most people develop a little more stiffness but may not be too troubled. Many people develop increasing symptoms and need assessment and treatment.

Making the diagnosis

The Hand specialist who sees the patient will ask questions about their symptoms, when they started, how they progressed, what treatment (if any) they have had and other questions relevant to the problems. They will then examine the patient looking at their elbows, wrists and hands. Stressing i.e. pushing on the affected joint is usually uncomfortable. It is necessary to demonstrate some tenderness to confirm the site of the symptoms but this should not be too painful. The specialist may measure the range of motion in the joint with a special angular ruler (goniometer). This will help guide their advice to the patient.

What test(s) might be performed?

Tests (also known medically as Investigations) include X-rays, scans, blood tests and particularly in the hand electrical tests (known as EMGs or Neurophysiology). These may be used to help make or confirm a diagnosis after a patient has described their symptoms and been examined.

In elbow arthritis the diagnosis is usually obvious after listening to and examining a patient but an elbow X-ray would typically taken on the day of the consultation to delineate the extent of joint damage. This does not however correlate well with symptoms. Thus a patient may have mild joint damage but marked symptoms and vice versa. Generally no other tests are required but sometimes in less clear cases or when looking for a loose body (see above) an MRI scan or CT scan may be requested. These would be performed at a later date.

An MRI scanner is usually a short tunnel which the patient’s arms and top half of the body go into. Once in the tunnel a loud magnet is spun around and images of the bones and soft tissues created. Some people find the tunnel rather claustrophobic. If any patient doubts whether they would tolerate the scan they are best advised to visit the scanner department in advance. The films will be reported by a radiologist but also reviewed by the Hand specialist who will advise the patient accordingly.

A CT (or CAT) scanner is a short large open tunnel. The patient lies on a bed and passes through the tunnel whilst X-rays are shone from various directions at the area of the body being investigated. It is particularly useful for showing bone abnormalities but less good at investigating soft tissue problems. The films will be reported by a radiologist but also reviewed by the Hand specialist who will advise the patient accordingly.

Treatment:

What are the non-operative treatments?

Treatment should start with non-operative options. These begin with activity modification such as avoiding repetitive or heavy lifting and impact work such as hammering. Most patients will have already tried these by the time they come for advice. Physiotherapy may help improve the range of movement if there is not too much pain. If there is much pain this needs to be addressed first. Pain killers particularly anti-inflammatory analgesics, such as Ibuprofen (Nurofen) and Diclofenac (Voltarol) can be very helpful for arthritic pains. These can be applied as a gel, massaging the area, or taken orally, assuming there is no history of indigestion.

If this is still insufficient then a steroid injection would usually be recommended. An injection is given of a long-acting steroid, such as Depomedrone or Triamcinolone, with some local anaesthetic into the joint at the bottom of the thumb.  The body naturally produces steroids to help dampen down inflammation. This appears to be one of the actions at this site.  Success cannot be guaranteed but in 70-80% of patients there is some significant benefit.  How long this lasts is unpredictable.  Some people only have a few weeks or months of benefit.  Others may have years or even life-long benefit such that they do not require further treatment, although may still have some mild on-going symptoms.  If one injection provides only short term benefit then it may well be repeated.  Patients often ask how many injections can be given.  There is no set rule about this. Typically, however, a second injection will work a little less well than the first (although this is not inevitable).  By the time three injections have been given, if this is over a shortish period, i.e. less than 1 year, then it is unlikely the third injection will be successful and most surgeons would recommend an alternative approach.  If, however, injections are only required infrequently, perhaps once every 2-3 years, then having a fourth or fifth injection would, in themselves, be a lot safer than having an operation, and if they give benefit this is reasonable.  There are risks. The biggest risk is of failure. There are risks of some pain for a few days, although that is usually minimised by taking pain-killers, starting while the area is still numb from the local anaesthetic.  In theory there is a risk of infection, but this seems very rare and has not occurred in our Practice in over 10 years.  The main other risk is some thinning of the skin. This can present with some pallor and a little less bulk at the site and occasionally an increased tendency to bleeding if the area is knocked.  This is very uncommon with this injection but is common with some other injections.  If it does occur then that is a relative contra-indication to further injections, i.e. the patient’s surgeon would probably decide not to go ahead with further injections because of the risks of further local damage.

Splints may help straighten joints that will not straighten out (extend) well but are only infrequently used in elbow arthritis.

What does the operation involve?

There are various operative procedures available. By and large one should start with the simplest operation that is likely to work and build up from there. The main operations are: elbow arthroscopy; open elbow debridement; and elbow replacement.

Elbow arthroscopy: Also known as keyhole or telescopic surgery the surgeon looks in the joint with a special telescope. It helps to make or confirm a diagnosis and allows for both removal of a loose body (see above) if there is one and debridement i.e. removal of inflammatory and other unnecessary tissue. This is performed under general anaesthetic. There will be 2-4 short (c.1cm) incisions in the skin which do not need stitching. The arm will be covered in a bulky dressing.

The total time in hospital is usually about 4-5 hours.

Elbow debridement: This is a substantially bigger undertaking used to address marked elbow arthritis with pain and a significant limitation in movement. A variant on this suited primarily to a lack of elbow straightening is the Outerbridge-Kashiwagi procedure. In this operation a smaller incision is used and the surgery is maily to the back of the joint. This is performed under general anaesthetic often with a small tube introduced in the upper arm to keep the arm numb for several days post-operatively. There will be single incision in the skin at the back of the elbow running in the line of the arm for about 8-10 cm. At operation the elbow joint is opened whilst protecting the important structures especially the ulnar nerve. The excess soft tissue and usually a lot of bone is removed whilst preserving the existing joint surfaces. At the end of the operation the deep structures are repaired and the skin closed with absorbable sutures or clips which are removed in clinic after about 2 weeks. The arm will be covered in a bulky dressing or plaster of Paris particularly to maintain straightening.

The total time in hospital is usually 3-4 days (2-3 nights) to allow for excellent early pain control.

Elbow replacement: Also known as elbow arthroplasty this has not been very successful for elbow osteoarthritis. It is very successful in patients with rheumatoid arthritis but their demands on the joint are typically a lot less. In osteoarthritis even in good operative series the failure rate is around 50% at 5 years so the indications for elbow replacement in osteoarthritis are small mainly for the older age group (70+) who will wear the joint less hard.  This is performed under general anaesthetic often with a small tube introduced in the upper arm to keep the arm numb for several days post-operatively. There will be single incision in the skin at the back of the elbow running in the line of the arm for about 8-10 cm. At operation the elbow joint is opened whilst protecting the important structures especially the ulnar nerve. The excess soft tissue and usually a lot of bone is removed allowing implantation of a metal segment in the arm bone (humerus) and one of the forearm bones (ulna) linked with a metal and plastic linkage. At the end of the operation the deep structures are repaired and the skin closed with absorbable sutures or clips which are removed in clinic after about 2 weeks. The arm will be covered in a plaster of Paris particularly to maintain straightening.

The total time in hospital is usually 3-4 days (2-3 nights) to allow for excellent early pain control.

Your Hand specialist will guide you on which particular operation is most appropriate.

What happens in the next few weeks?

The care of the hand in the post-operative period is very important in helping to ensure a good result. Initially the aims are comfort and elevation. These are met by keeping the hand up (elevated) especially in the first few days and by use of a long acting local anaesthetic (Bupivicaine). The local anaesthetic lasts at least 12 hours and sometimes 48 hours. Patients should start taking painkillers before the pain starts (i.e. on return home for elbow arthroscopy) and for at least 24 hours from there. This way most of our patients report little or any pain.

Elbow arthroscopy: The bandage can be removed after 2-7 days, leaving a sticky dressing beneath. The patient or GP practice nurse can do this. If well healed at that stage then the wound can be left open (exposed). If in doubt it can be covered with a light dressing for a few more days.  The patient is reviewed in clinic between 2-4 weeks following the operation.

The elbow can be used for normal activity after the first few days.  Most patients can drive after a week or two.  Most patients return to work in 1-2 weeks, but this varies with occupation; heavy manual work usually takes about 4 weeks. The wound should be massaged by the patient 3 times a day with a bland soft cream for 3 months once the wound is well healed (typically after 2 weeks). This reduces the scar sensitivity which can be a nuisance. If this is marked a physiotherapy may be organised to help reduce the scar tenderness but this is rarely required.

Elbow debridement/replacement: The initial post-operative period is crucial to a successful outcome. Above all pain needs to be well managed. Ideally the patient should be pain free for the first few days whilst in hospital. At around 3 days the plaster is removed and physiotherapy started with a night splint to help retain good straightening. It is important to gain both a good return of bending (flexion) but not lose too much straightening. Almost inevitably some straightening will be lost and full bending will NOT be regained. The aim is a range of movement with straightening within 30⁰ of full and bending to 120-130⁰. Most of the movement gained following surgery occurs in the first 6 weeks and this time must be used productively to ensure a good result. The key is regular long gentle stretches both into straightening and into bending. Ideally these should be performed for 5 mins in each direction (feeling the stretch but without pain) once an hour. In practical terms most people mange 5-6 times a day. Elevation and icing the elbow also help reduce swelling and thus pain and improve movement.

Most patients can drive after a week or two.  Few patients return to work before 6 weeks, but this varies with occupation; heavy manual work usually takes at least 3 months if ever. The wound should be massaged by the patient 3 times a day with a bland soft cream for 3 months once the wound is well healed (typically after 2 weeks). This reduces the scar sensitivity which can be a nuisance.

What are the results of the operation?

Elbow arthroscopy: At least 85% of patients in studies say they have a good or excellent result following this operation. Locking is almost always resolved but can recur.

Elbow debridement: Most patients (>80%) achieve a good range of movement and reduced pain but it is a significant operation for the elbow and some patients end with just as much stiffness or are worse.

Elbow replacement: Most patients (>95%) achieve a good range of movement and relief of their pain. In 12 years only one patient with rheumatoid arthritis who has had elbow replacement has had to have a re-do operation in our Hand and Elbow department.

Are there any risks?

All interventions in medicine have risks. In general the larger the operation the greater the risks. For elbow surgery the risks include (the more severe risks are more common with the bigger operations):

• The scar may be tender, in about 10% of patients. This usually improves with scar massage, over 3 months.
• Aching in the elbow following debridement may take 3-6 mionths to settle and that may never be fully.
• Grip strength can also take some months to return to normal.
• Stiffness in the elbow may be greater than before surgery. Careful post-operative follow-up and physiotherapy help to minimise this.
• Numbness can occur around the scar but this rarely causes any functional problems. Following elbow replacement there is a higher incidence of longer term nerve dysfunction particularly in the ulnar nerve.
• Wound infections occur in about 1% of cases. These usually quickly resolve with antibiotics.
• For joint replacement there is a risk of long-term joint replacement failure requiring reoperation.
• Chronic Regional Pain Syndrome “CRPS”. This is a rare but serious complication, with no known cause or proven treatment.  The nerves in the hand “over-react”, causing swelling, pain, discolouration and stiffness, which improve very slowly.
• Any operation can have unforeseen consequences and leave a patient worse than before surgery. This is particularly a concern for elbow debridement.