Elbow Arthritis

Elbow arthritis encompasses inflammatory and degenerative conditions affecting the elbow joint, leading to pain, stiffness, and functional limitation. Unlike hip and knee arthritis where primary osteoarthritis predominates, elbow arthritis is most commonly post-traumatic or inflammatory (rheumatoid arthritis).

• Prevalence: Less than 1% of population (much less common than hip/knee)
• Primary OA: Rare, usually in manual laborers with repetitive stress
• RA: Most common inflammatory cause, typically bilateral
• Post-traumatic: Common after fractures, dislocations, or chronic instability
• Age: Peak 50-70 years
• Gender: RA more common in females, post-traumatic equal distribution

Elbow arthritis significantly impacts activities of daily living including eating, personal hygiene, and work. Unlike lower extremity arthritis, elbow involvement affects both dominant and non-dominant arms, with bilateral RA causing severe functional impairment.

• Ulnohumeral joint: Primary hinge (flexion-extension 0-150°)
• Radiocapitellar joint: Valgus stability, load transmission
• Proximal radioulnar joint: Forearm rotation (pronation-supination)

• Medial collateral ligament (MCL): Primary valgus stabilizer
• Lateral collateral ligament (LCL): Primary varus stabilizer
• Capsule: Anterior and posterior capsular constraints
• Muscles: Dynamic stabilizers (biceps, triceps, brachialis)

• Synovial inflammation → cartilage destruction
• Pannus formation erodes articular surfaces
• Ligamentous laxity → instability
• Bilateral involvement common

• Cartilage damage from initial injury
• Malalignment → abnormal load distribution
• Instability → recurrent trauma
• Osteochondral defects → progressive degeneration

• Rare, usually manual laborers
• Repetitive stress → cartilage wear
• Loose bodies common
• Usually unilateral

• Pain: Location, character, timing (activity-related vs rest)
• Stiffness: Loss of flexion-extension, pronation-supination
• Instability: Feeling of giving way, recurrent dislocations
• Trauma history: Previous fractures, dislocations
• Systemic symptoms: RA features (morning stiffness, bilateral, systemic)

• AP and lateral views: Joint space narrowing, osteophytes, loose bodies
• Stress views: Instability assessment
• Comparison views: Contralateral elbow for reference

• 3D reconstruction: Bone stock assessment, version analysis
• Loose body detection: More sensitive than X-ray
• Preoperative planning: For TEA or debridement

• Cartilage assessment: Early changes, osteochondral defects
• Synovial evaluation: RA pannus, synovitis
• Ligament integrity: MCL, LCL assessment
• Ulnar nerve: Cubital tunnel evaluation

• RA workup: RF, anti-CCP, ESR, CRP
• Infection markers: If concern for septic arthritis
• Bone health: If considering TEA

• EMG/NCS: Ulnar nerve function if symptomatic
• Brachial plexus: If neurological symptoms

• Pain at the extremes of motion (terminal extension and end-range flexion) with a comparatively pain-free mid-arc — the reverse of the diffuse rest-and-motion pain of inflammatory disease
• Loss of terminal extension is usually the first and most consistent deficit
• Mechanical symptoms — catching, locking, and grinding from loose bodies and impinging osteophytes
• Ulnar nerve traction or compression symptoms are common, because posteromedial olecranon osteophytes and a contracted posterior capsule crowd the cubital tunnel — assess the nerve in every case and decompress it if flexion is limited (for example, fewer than 100 degrees) or if there are neuritic symptoms

osteophytes at the tips of the olecranon and coronoid and within their fossae, with loose bodies, but with relative preservation of the ulnohumeral joint space. This retained central space is the single most useful feature distinguishing primary OA from rheumatoid and post-traumatic arthritis, both of which show global joint-space loss.

because these patients are often younger and higher-demand than the ideal TEA candidate, treatment is joint-preserving. The Outerbridge–Kashiwagi ulnohumeral arthroplasty ("OK procedure") is the classic open operation: through a posterior approach a fenestration is created through the floor of the olecranon fossa, giving access to remove both posterior (olecranon) and anterior (coronoid) osteophytes and loose bodies through a single window, with capsular release to restore the arc. The same goals — osteophyte excision, loose-body removal, and osteocapsular release — are achievable arthroscopically in experienced hands, with the systematic-review evidence above showing an average arc gain of roughly 23 degrees and a Mayo Elbow Performance Score improvement of about 24 points. Osteophytes and motion loss may recur over time, but joint preservation defers arthroplasty in a population for whom lifelong TEA load restrictions are poorly suited.

• Recurrent haemarthrosis deposits iron (haemosiderin) in the synovium, driving a chronic proliferative, hypervascular synovitis
• The inflamed synovium releases enzymes and cytokines that degrade cartilage, while the friable neovascular tissue bleeds again — a self-perpetuating cycle
• Characteristic changes include an enlarged, overgrown radial head, widening of the trochlear notch, radiocapitellar destruction, and (in children) epiphyseal overgrowth from chronic hyperaemia

• The foundation is factor replacement / prophylaxis to abolish recurrent bleeds and protect the target joint; this is haematologist-led
• For persistent bleeding despite prophylaxis, synovectomy reduces bleed frequency: radiosynovectomy (intra-articular radioactive isotope such as yttrium-90, rhenium-186, or phosphorus-32) is minimally invasive and first-line in many centres, with surgical (arthroscopic or open) synovectomy reserved for failure
• In end-stage radiocapitellar disease, radial head excision with synovectomy relieves pain and improves forearm rotation
• Total elbow arthroplasty is reserved for end-stage destruction but carries higher infection and revision risk in these typically younger patients

• RA: 60-70% achieve adequate control with medical management
• Post-traumatic: 40-50% improve with conservative measures
• Duration: Variable, may delay surgery for years

• Improvement: 60-70% of patients
• Duration: 2-5 years of benefit
• May delay: Need for TEA

• RA patients: 90% 10-year survival, 90% pain relief, 100° functional arc
• Trauma patients: 75% 10-year survival, 85% pain relief
• Satisfaction: 85-90% satisfied at 10 years
• Functional: 30-130° flexion arc for ADLs

• Aseptic loosening: Most common long-term failure (15% at 10 years)
• Revision: 15% revision rate at 10 years
• Weight restrictions: Lifelong (under 5 kg single, under 2 kg repetitive)