Elbow arthritis can be due to osteoarthritis (wear and tear arthritis), post-traumatic arthritis (after a fracture or dislocation) or due to rheumatoid arthritis (a systemic, inflammatory disease). Elbow arthritis can limit function, cause pain, and lead to serious impairment of the arm.
Initial treatment should be nonoperative, with an injection, activity modification, and occasionally physical therapy. If that is ineffective, then options depend on how advanced the arthritis is and the symptoms it is causing. Pain at terminal motion (at full flexion or full extension) is usually due to bone spurs, which are the body’s reaction to arthritis. Pain during mid-motion is usually due to loss of the joint’s normal slippery cartilage surface. Pain during rest is usually due to reactive synovitis (inflammation of the joint lining in response to the mechanical irritation of the arthritis). Catching, locking, and feelings like something is ‘loose’ in the joint are often due to loose bodies, which are pieces of bone spurs and damaged cartilage that have broken off and are floating around the joint.
If the arthritis is mild, an arthroscopic debridement can help. Arthroscopy can remove bone spurs, inflammation, and any loose bodies in the joint. This often relieves pain during terminal motion and often at rest. Mid-motion pain will usually not be improved, and if the arthritis is significant, the inflammation and rest pain will recur. In some patients, such as those who have already had their ulnar nerve moved (putting it at risk unless it’s visualized), or those who are undergoing additional surgeries, elbow debridement may be better performed through an open incision.
If stiffness is a problem, release of the restraining joint capsule (the balloon around the joint) may be performed, either openly or arthroscopically. In order to maintain the motion that is gained during surgery, extensive physical therapy will be required after surgery. When significant stiffness is present, the ulnar nerve will usually be scarred in, and should be released or transposed (moved) to avoid problems with traction on the nerve once motion is restored.
If mid-motion pain is prominent, then cartilage loss has probably occurred. Simple debridement of bone spurs will not provide pain relief. In older patients, a total elbow replacement is an effective option. Total elbow replacement usually involves a hospital stay of 1-2 nights. The elbow is splinted for approximately 2 weeks, and then motion is begun. Pain relief and function are very good, but elbow replacements can loosen over time. To protect against this, there is a lifetime lifting limit of 1-2 pounds repetitively and 5-10 pounds for a single time once in a while.
In young patients who cannot live with this restriction, the best operation may be a fascial-interposition arthroplasty, where the achilles tendon from a cadaver is used to resurface the elbow joint. This tendon is broad and slippery, and may provide a pain-free surface for the reconstructed elbow. This surgery also usually requires a night in the hospital. In order to keep the joint surfaces apart to maximize healing and motion, an external fixator is placed about the elbow. This involves placing 2 metal screws into the humerus (the large bone above the elbow) and 2 metal screws into the ulna (one of the forearm bones), connected by a hinge to allow motion. The fixator remains in place for 3-6 weeks, and is then removed under general anesthesia as a second procedure. While fascial-interposition arthroplasty is not as predictable as a total joint replacement, it does very well in select patients without ligament or bone loss. And unlike a total elbow replacement, once the fascial-interposition arthroplasty is healed, the elbow can be used within the limits of pain, without lifting restrictions.