ELBOW ARTHRITIS
Post-traumatic vs Inflammatory | Conservative First | TEA for End-Stage | Ulnar Nerve
ELBOW ARTHRITIS TYPES
Critical Must-Knows
- RA is most common inflammatory cause - bilateral involvement, systemic disease
- Post-traumatic follows fractures, dislocations, or chronic instability
- Conservative management first - NSAIDs, injections, activity modification
- TEA indicated when conservative fails, age over 60, low demand
- Ulnar nerve commonly affected - cubital tunnel syndrome in 30-50%
Examiner's Pearls
- "RA elbow arthritis: bilateral, systemic, medical management first
- "Post-traumatic: history of fracture/dislocation, may have instability
- "TEA best outcomes in RA (90% 10-year survival) vs trauma (75%)
- "Ulnar nerve must be assessed and protected in all elbow procedures
Critical Elbow Arthritis Exam Points
RA vs Post-traumatic
Rheumatoid arthritis is the most common inflammatory cause, typically bilateral with systemic features. Post-traumatic follows fractures, dislocations, or chronic instability. Always assess for instability and ulnar nerve involvement.
Conservative First
Medical management is first-line for RA (DMARDs, biologics). Activity modification and injections for post-traumatic. Surgery reserved for failed conservative management in appropriate patients.
TEA Indications
Total elbow arthroplasty indicated when conservative fails, age over 60, low demand. RA patients have best outcomes (90% 10-year survival). Trauma patients have higher failure rates (75% 10-year survival).
Ulnar Nerve
Ulnar nerve commonly affected in elbow arthritis (30-50% cubital tunnel syndrome). Must assess preoperatively and protect during surgery. Nerve complications occur in 10-15% of TEA procedures.
Quick Decision Guide - Elbow Arthritis Management
| Patient Scenario | Etiology | Treatment | Key Consideration |
|---|---|---|---|
| RA, bilateral, age 65, failed medical management | Inflammatory (RA) | TEA both sides (staged) | Best outcomes - 90% 10-year survival |
| Post-traumatic, age 55, moderate symptoms | Post-traumatic OA | Conservative, debridement if needed | TEA too young - wait until over 60 if possible |
| Post-traumatic, age 75, unreconstructible fracture | Acute fracture | Primary TEA | 75% 10-year survival, faster rehab than ORIF |
| Young, high demand, post-traumatic | Post-traumatic OA | Avoid TEA, consider interposition or fusion | TEA contraindicated - high failure risk |
RAPIDElbow Arthritis Causes
Memory Hook:RAPID progression of elbow arthritis - RA and post-traumatic are most common.
FRAILTEA Indications
Memory Hook:FRAIL patients are ideal for TEA - elderly, low demand, inflammatory causes.
CUBITALUlnar Nerve Assessment
Memory Hook:CUBITAL tunnel syndrome is common - assess and protect the ulnar nerve.
Overview and Epidemiology
Definition: 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).
Epidemiology:
- 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
Clinical Significance: 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.
Why Elbow Arthritis is Different
Elbow arthritis differs from hip/knee arthritis: primary OA is rare (usually post-traumatic or inflammatory), the joint tolerates less cartilage loss before symptoms, and treatment options are more limited. TEA is less common than hip/knee replacement due to higher complication rates and stricter patient selection criteria.
Anatomy and Pathophysiology
Elbow Joint Anatomy:
Three Articulations:
- Ulnohumeral joint: Primary hinge (flexion-extension 0-150°)
- Radiocapitellar joint: Valgus stability, load transmission
- Proximal radioulnar joint: Forearm rotation (pronation-supination)
Stabilizing Structures:
- 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)
Pathophysiology:
Rheumatoid Arthritis:
- Synovial inflammation → cartilage destruction
- Pannus formation erodes articular surfaces
- Ligamentous laxity → instability
- Bilateral involvement common
Post-traumatic:
- Cartilage damage from initial injury
- Malalignment → abnormal load distribution
- Instability → recurrent trauma
- Osteochondral defects → progressive degeneration
Primary OA:
- Rare, usually manual laborers
- Repetitive stress → cartilage wear
- Loose bodies common
- Usually unilateral
Classification Systems
Classification by Cause
Type I: Inflammatory
- Rheumatoid arthritis (most common)
- Systemic lupus erythematosus
- Psoriatic arthritis
- Juvenile idiopathic arthritis
- Features: Bilateral, systemic, synovial inflammation
Type II: Post-traumatic
- After fractures (distal humerus, radial head, olecranon)
- After dislocations (simple or complex)
- Chronic instability
- Features: Unilateral, history of trauma, may have malalignment
Type III: Primary Degenerative
- Primary osteoarthritis (rare)
- Hemophilic arthropathy
- Neuropathic (Charcot)
- Features: Usually unilateral, specific risk factors
Understanding etiology guides treatment approach and predicts outcomes.
Clinical Assessment
History:
- 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)
Physical Examination:
Inspection:
- Swelling, deformity, scars
- Muscle atrophy (especially triceps)
- Carrying angle (cubitus valgus/varus)
Palpation:
- Joint line tenderness
- Ulnar nerve (cubital tunnel)
- Loose bodies
- Synovial thickening (RA)
Range of Motion:
- Flexion-extension: Normal 0-150°, functional arc 30-130°
- Pronation-supination: Normal 80° each direction
- Stiffness pattern: Capsular vs mechanical block
Special Tests:
- Valgus stress: MCL integrity
- Varus stress: LCL integrity
- Tinel's sign: Ulnar nerve at cubital tunnel
- Instability: Apprehension, pivot shift
Neurological Assessment:
- Ulnar nerve: Sensation (ulnar 1.5 digits), motor (interossei, FDP)
- Median nerve: Sensation, motor (thenar muscles)
- Radial nerve: Sensation, motor (wrist/finger extension)
Investigations
Plain Radiographs:
- AP and lateral views: Joint space narrowing, osteophytes, loose bodies
- Stress views: Instability assessment
- Comparison views: Contralateral elbow for reference
CT Scan:
- 3D reconstruction: Bone stock assessment, version analysis
- Loose body detection: More sensitive than X-ray
- Preoperative planning: For TEA or debridement
MRI:
- Cartilage assessment: Early changes, osteochondral defects
- Synovial evaluation: RA pannus, synovitis
- Ligament integrity: MCL, LCL assessment
- Ulnar nerve: Cubital tunnel evaluation
Laboratory Studies:
- RA workup: RF, anti-CCP, ESR, CRP
- Infection markers: If concern for septic arthritis
- Bone health: If considering TEA
Electrodiagnostic Studies:
- EMG/NCS: Ulnar nerve function if symptomatic
- Brachial plexus: If neurological symptoms
Management Algorithm
Treatment Decision Framework
The key decision is conservative vs surgical management. Conservative management is first-line for all patients. Surgery (debridement, TEA) is reserved for failed conservative management in appropriate patients (age over 60, low demand for TEA).
First-Line Treatment
Medical Management (RA):
- DMARDs (methotrexate, sulfasalazine)
- Biologics (anti-TNF, anti-IL6)
- Corticosteroids (oral or intra-articular)
- Continue until pain uncontrolled or function severely limited
Non-Pharmacological:
- Activity modification
- Physiotherapy (maintain ROM, strengthen)
- Bracing (elbow brace for support)
- Weight management
Injections:
- Corticosteroid injection (temporary relief, 3-6 months)
- Hyaluronic acid (limited evidence)
- Maximum 2-3 lifetime injections
Expected Outcomes:
- RA: 60-70% achieve adequate control with medical management
- Post-traumatic: 40-50% improve with conservative measures
- Primary OA: 50-60% respond to conservative treatment
Conservative management should be exhausted before considering surgery.
Surgical Technique
Arthroscopic Elbow Debridement
Indications:
- Loose bodies
- Osteophytes causing impingement
- Early arthritis with mechanical symptoms
- Capsular contracture
Technique:
- Standard arthroscopic portals (anteromedial, anterolateral, posterolateral)
- Remove loose bodies
- Debride osteophytes (coronoid, olecranon)
- Capsular release if stiff
- Radial head excision if arthritic
Outcomes:
- 60-70% improvement
- Temporary benefit (2-5 years)
- May delay need for TEA
Arthroscopic debridement provides temporary relief and may delay definitive surgery.
Complications
| Complication | Incidence | Risk Factors | Management |
|---|---|---|---|
| Ulnar nerve injury | 10-15% (TEA) | Cubital tunnel disease, previous surgery, transposition | Observation if neuropraxia, exploration if transection, may need transposition |
| Aseptic loosening | 15% at 10 years | High demand, trauma indication, young age | Revision TEA with longer stems, bone graft |
| Triceps insufficiency | 5-10% | Triceps-reflecting approach, inadequate repair | Extension lag, may need revision repair or tendon transfer |
| Infection | 2-3% | Previous surgery, RA, immunosuppression | Debridement, antibiotics, may need explant |
| Instability | 2-4% | Unlinked designs, ligament deficiency | Revision to linked design or ligament reconstruction |
| Heterotopic ossification | 5-10% | Trauma history, extensive dissection | Prophylaxis with indomethacin, may need excision |
Ulnar Nerve Complications
Ulnar nerve complications occur in 10-15% of TEA procedures. The nerve must be identified and protected at the start of surgery. Transposition is not always required and may increase complications. If symptomatic preoperatively, transposition should be considered. Postoperative neuropraxia usually resolves but may be permanent.
Postoperative Care and Rehabilitation
Total Elbow Arthroplasty Rehabilitation
Immediate (0-48 hours):
- Splint at 90° flexion
- Elevation to reduce swelling
- Pain control
- Ulnar nerve monitoring
Early (2-6 weeks):
- Remove splint at 2 weeks
- Gentle passive motion (avoid forced extension)
- Active-assisted motion
- No active extension until 6 weeks (protect triceps)
Intermediate (6-12 weeks):
- Active extension strengthening
- Progressive ROM exercises
- Light activities (under 2 kg)
- Return to ADLs
Long-term:
- Lifelong weight restrictions (under 5 kg single, under 2 kg repetitive)
- Avoid impact activities
- Regular follow-up for loosening
Proper rehabilitation optimizes outcomes and prevents complications.
Outcomes and Prognosis
Conservative Management Outcomes:
- RA: 60-70% achieve adequate control with medical management
- Post-traumatic: 40-50% improve with conservative measures
- Duration: Variable, may delay surgery for years
Surgical Outcomes:
Arthroscopic Debridement:
- Improvement: 60-70% of patients
- Duration: 2-5 years of benefit
- May delay: Need for TEA
Total Elbow Arthroplasty:
- 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
Long-term Considerations:
- 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)
Predictors of Success
Good outcomes are associated with: RA etiology (better than trauma), age over 60, low demand, compliant with restrictions, and optimal surgical technique. Poor outcomes are associated with: young age, high demand, trauma indication, non-compliance, and complications.
Evidence Base and Key Trials
Total Elbow Arthroplasty Outcomes
- RA patients: 90% 10-year survival with semi-constrained TEA
- Trauma patients: 75% 10-year survival
- Aseptic loosening most common failure (15% at 10 years)
- Ulnar nerve complications in 10-15%
Conservative Management RA
- DMARDs and biologics control RA effectively
- 60-70% achieve adequate elbow control without surgery
- Early aggressive treatment prevents joint destruction
Arthroscopic Debridement
- 60-70% improvement in symptoms
- Temporary benefit (2-5 years)
- May delay need for TEA in young patients
Ulnar Nerve in Elbow Arthritis
- 30-50% of elbow arthritis patients have cubital tunnel syndrome
- Must assess preoperatively
- Transposition not always required but consider if symptomatic
TEA in Trauma
- Primary TEA for unreconstructible distal humerus fractures in elderly
- 75% 10-year survival vs 90% in RA
- Faster rehabilitation than ORIF
- Higher complication rate than RA patients
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: RA vs Post-traumatic (~2-3 min)
"A 65-year-old patient presents with bilateral elbow pain and stiffness. Examination shows synovial thickening, limited ROM, and ulnar nerve symptoms. How do you differentiate between rheumatoid arthritis and post-traumatic arthritis, and what is your management approach?"
Scenario 2: TEA Indications and Technique (~3-4 min)
"A 72-year-old patient with rheumatoid arthritis presents with severe elbow pain and stiffness despite optimal medical management. Walk me through your decision-making for total elbow arthroplasty, including patient selection, surgical approach, and key technical points."
Scenario 3: Ulnar Nerve Complication (~2-3 min)
"A patient presents 3 months after total elbow arthroplasty with numbness and weakness in the ulnar distribution. How do you assess and manage this?"
MCQ Practice Points
Etiology Question
Q: What is the most common cause of inflammatory elbow arthritis? A: Rheumatoid arthritis. Unlike hip and knee where primary OA predominates, elbow arthritis is most commonly inflammatory (RA) or post-traumatic. Primary OA of the elbow is rare.
Treatment Question
Q: What is the first-line treatment for rheumatoid elbow arthritis? A: Medical management with DMARDs and biologics. Surgery (TEA) is reserved for failed medical management in appropriate patients (age over 60, low demand).
Surgical Technique Question
Q: What is the 10-year survival rate of total elbow arthroplasty in rheumatoid arthritis patients? A: 90% 10-year survival in RA patients. This is better than trauma patients (75% 10-year survival). RA is the primary indication with best outcomes.
Complications Question
Q: What is the most common complication after total elbow arthroplasty? A: Ulnar nerve complications occur in 10-15% of procedures. Most are neuropraxias that recover, but some may be permanent. The nerve must be identified and protected at the start of surgery.
Indications Question
Q: What are the weight restrictions after total elbow arthroplasty? A: Lifelong restrictions: under 5 kg for single lift, under 2 kg for repetitive activities. These restrictions are essential to prevent aseptic loosening, which is the most common long-term failure (15% at 10 years).
Australian Context and Medicolegal Considerations
Australian Practice Patterns
- Elbow arthritis less common than hip/knee (under 1% prevalence)
- RA management follows Australian Rheumatology Association guidelines
- TEA performed in major centers (1-2 per year per surgeon)
- Medical management optimized before surgical referral
Medicolegal Considerations
- Informed consent: Must discuss weight restrictions extensively
- Ulnar nerve: High risk of complications - must document assessment and protection
- Alternatives: Must discuss conservative management and debridement before TEA
- Outcomes: RA vs trauma outcomes differ - must counsel appropriately
Medicolegal Risk Factors
Key documentation requirements:
- Preoperative ulnar nerve assessment and documentation
- Discussion of weight restrictions and patient acceptance
- Alternative treatments discussed (conservative, debridement)
- RA vs trauma outcome differences explained
- Informed consent for lifelong restrictions
Common litigation issues:
- Ulnar nerve injury without proper documentation of protection
- Aseptic loosening in non-compliant patients
- Failure to discuss alternatives
- Inadequate informed consent for restrictions
Proper documentation and comprehensive informed consent minimize medicolegal risk.
Elbow Arthritis
High-Yield Exam Summary
Key Etiology
- •RA: most common inflammatory, bilateral, systemic
- •Post-traumatic: after fractures/dislocations, unilateral
- •Primary OA: rare, manual laborers
- •Hemophilic: bleeding arthropathy
Management Algorithm
- •Conservative first: medical management (RA), activity modification, injections
- •Surgical: debridement (temporary), TEA (definitive)
- •TEA indications: failed conservative, age over 60, low demand
- •Weight restrictions: under 5 kg single, under 2 kg repetitive (lifelong)
TEA Outcomes
- •RA: 90% 10-year survival, 90% pain relief
- •Trauma: 75% 10-year survival, 85% pain relief
- •Functional arc: 30-130° flexion for ADLs
- •Aseptic loosening: 15% at 10 years (most common failure)
Ulnar Nerve
- •30-50% of elbow arthritis patients have cubital tunnel syndrome
- •Must assess preoperatively in all cases
- •10-15% complication rate in TEA
- •Protect at start of surgery, transposition if symptomatic