Elbow Arthritis

Elbow arthritis covers the inflammatory and degenerative conditions of the elbow that cause pain, stiffness and loss of function. It differs from the hip and knee, where primary osteoarthritis predominates: at the elbow the cause is most commonly post-traumatic or inflammatory, usually rheumatoid arthritis.

Who. Symptomatic disease affects less than 1% of the population, far fewer than hip or knee arthritis, and peaks at 50-70 years.

• Rheumatoid arthritis - the most common inflammatory cause, typically bilateral, and more common in women
• Post-traumatic arthritis - common after fractures, dislocations or chronic instability, with an equal sex distribution
• Primary osteoarthritis - rare, usually in manual labourers with repetitive stress
• Other causes - haemophilic, crystalline and neuropathic arthropathy

Why it matters. Elbow arthritis cuts into eating, personal hygiene and work. Unlike lower-limb arthritis it involves the dominant and non-dominant arms alike, and bilateral rheumatoid disease causes severe functional impairment.

The joint. The elbow has three articulations:

• Ulnohumeral - the primary hinge, flexion-extension 0-150°
• Radiocapitellar - valgus stability and load transmission
• Proximal radioulnar - forearm rotation, pronation and supination

The stabilisers. The medial collateral ligament is the primary valgus stabiliser and the lateral collateral ligament the primary varus stabiliser. The anterior and posterior capsule add their constraint, and biceps, triceps and brachialis stabilise the joint dynamically.

Rheumatoid arthritis. Synovial inflammation destroys the cartilage, and pannus erodes the articular surfaces. Ligamentous laxity follows, and with it instability.

Post-traumatic arthritis. The injury damages cartilage at the outset. Malalignment then distributes load abnormally, instability exposes the joint to recurrent trauma, and osteochondral defects progress to degeneration.

Primary osteoarthritis. Repetitive stress wears the cartilage. The disease is usually unilateral, and loose bodies are common.

Classify by cause first: the cause guides the treatment and predicts the outcome.

History. The questions that sort the cause and the treatment:

• Pain - where it is, its character, and whether it comes with activity or at rest
• Stiffness - loss of flexion-extension or of pronation-supination
• Instability - a feeling of giving way, recurrent dislocations
• Previous fractures or dislocations
• Systemic features of rheumatoid arthritis - morning stiffness, bilateral involvement

Look and feel. Inspect for swelling, deformity, scars, muscle atrophy (especially of triceps) and the carrying angle, cubitus valgus or varus. Palpate for joint-line tenderness, loose bodies and the synovial thickening of rheumatoid disease, and examine the ulnar nerve in the cubital tunnel, posterior to the medial epicondyle.

Movement. Normal flexion-extension is 0-150° and the functional arc 30-130°; pronation and supination are normally 80° each. Decide whether stiffness is capsular or a mechanical block.

View larger

Special tests. Each stresses one structure:

• Valgus stress - MCL integrity
• Varus stress - LCL integrity
• Tinel's sign at the cubital tunnel - the ulnar nerve
• Apprehension and pivot shift - instability

Neurology. Assess every arthritic elbow for instability and for ulnar nerve involvement. The ulnar nerve is commonly affected, so examine and document it before every elbow operation: sensation in the ulnar 1.5 digits, and motor power in the interossei and FDP. Test the median nerve (sensation, thenar muscles) and the radial nerve (sensation, wrist and finger extension) as well.

Radiographs. AP and lateral views show joint-space narrowing, osteophytes and loose bodies. Stress views assess instability, and views of the contralateral elbow give a reference.

View larger

CT. More sensitive than radiographs for loose bodies, and with 3D reconstruction it assesses bone stock and version. It is used for preoperative planning before TEA or debridement.

View larger

View larger

MRI. Shows early cartilage change and osteochondral defects, rheumatoid pannus and synovitis, the integrity of the MCL and LCL, and the ulnar nerve in the cubital tunnel.

Blood tests. Rheumatoid factor, anti-CCP, ESR and CRP for the rheumatoid work-up; infection markers if septic arthritis is a concern; and bone health if TEA is being considered.

Neurophysiology. EMG and nerve conduction studies assess ulnar nerve function if the patient is symptomatic. Investigate the brachial plexus if there are neurological symptoms.

The decision. Conservative management is first-line for every patient and should be exhausted before surgery is considered. Surgery, debridement or TEA, is reserved for failed conservative management in the appropriate patient, and the options depend on age, demand and disease severity.

Conservative ManagementSurgical Options

Medical control of rheumatoid disease. Medical management is first-line in rheumatoid arthritis, and continues until pain is uncontrolled or function severely limited.

• DMARDs - methotrexate, sulfasalazine
• Biologics - anti-TNF, anti-IL6
• Corticosteroids - oral or intra-articular

Non-pharmacological measures. Activity modification, physiotherapy to maintain range and strength, an elbow brace for support, and weight management. With injections, activity modification is the first line for post-traumatic arthritis.

Injections. A corticosteroid injection gives temporary relief, for 3-6 months; hyaluronic acid has limited evidence. Allow a maximum of 2-3 injections in a lifetime.

Arthroscopic debridement. Removes loose bodies, excises osteophytes and releases the capsule. Indications:

• Loose bodies
• Osteophytes causing impingement
• Early arthritis with mechanical symptoms
• Capsular contracture

Open debridement. For advanced disease, or when extensive debridement is needed: the Outerbridge procedure (described under primary osteoarthritis below), radial head excision if arthritic, and capsular release.

Total elbow arthroplasty. A semi-constrained linked hinge, indicated for:

• Failed conservative management
• Age over 60 (preferred)
• Low demand
• End-stage arthritis
• Inflammatory arthropathy - rheumatoid arthritis (the primary indication), SLE, psoriatic arthritis

It is contraindicated by:

• Active infection
• Poor bone stock (absolute)
• Young age, under 60 (relative)
• High demand
• Non-compliant patient

View larger

View larger

Interposition arthroplasty. Fascia lata or allograft, for young patients in whom TEA is to be avoided. Results are variable and the evidence limited.

The ulnar nerve. Routine anterior transposition versus simple in situ release, or leaving the nerve undisturbed, remains debated. The evidence favours selective transposition for stiff elbows or preoperative symptoms rather than transposing every case.

Conservative treatment. In rheumatoid arthritis most patients achieve adequate control with modern treat-to-target medical management, which is why the end-stage rheumatoid elbow is now uncommon. In post-traumatic arthritis 40-50% improve with conservative measures, and in primary OA 50-60% respond. The benefit lasts a variable time and may delay surgery for years.

Arthroscopic debridement. Most patients improve symptomatically, and debridement may delay the need for TEA. The relief is temporary, put at 2-5 years, although none of the series cited here quantifies the response rate or its duration.

Total elbow arthroplasty. Rheumatoid patients do best, with 90% 10-year survival, 90% pain relief and a 100° functional arc, the 30-130° flexion arc for daily activities. Trauma patients have higher failure rates: 75% 10-year survival and 85% pain relief. At 10 years 85-90% of patients are satisfied. The largest single rheumatoid series in the evidence below (Sanchez-Sotelo, 461 elbows) reports 92% at 10 years.

The long term. Aseptic loosening is the most common long-term failure, at 15% at 10 years, and the revision rate at 10 years is also 15%.

Primary (idiopathic) osteoarthritis of the elbow has a distinctive clinical signature that separates it from inflammatory and post-traumatic disease. It classically affects the dominant arm of middle-aged men, particularly manual labourers, throwers and weight-training athletes.

Presentation. The pattern is distinctive:

• 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, usually the first and most consistent deficit
• Mechanical symptoms - catching, locking and grinding from loose bodies and impinging osteophytes

The 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.

Radiographs. Osteophytes form at the tips of the olecranon and coronoid and within their fossae, with loose bodies, but the ulnohumeral joint space is relatively preserved. That retained central space is the single most useful feature distinguishing primary OA from rheumatoid and post-traumatic arthritis.

View larger

Open joint-preserving surgery. These patients are often younger and higher-demand than the ideal TEA candidate, so treatment preserves the joint. The classic open operation is the Outerbridge–Kashiwagi ulnohumeral arthroplasty ("OK procedure"): through a posterior approach a fenestration is created through the floor of the olecranon fossa, and through that single window both the posterior (olecranon) and anterior (coronoid) osteophytes and the loose bodies are removed, with capsular release to restore the arc.

Arthroscopic joint-preserving surgery. Osteophyte excision, loose-body removal and osteocapsular release are achievable arthroscopically in experienced hands. The systematic review in the evidence below (Sochacki) found an average arc gain of roughly 23 degrees and a Mayo Elbow Performance Score improvement of about 24 points. Ulnar decompression is frequently combined with debridement, especially when preoperative flexion is limited.

Recurrence. 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.

The elbow is one of the commonest target joints in haemophilia A and B, alongside the knee and ankle. A target joint is conventionally defined as one that sustains at least three spontaneous bleeds within six months. Both the pathology and the perioperative rules differ fundamentally from the other causes of elbow arthritis.

The pathology. 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. The characteristic changes:

• An enlarged, overgrown radial head
• Widening of the trochlear notch
• Radiocapitellar destruction
• In children, epiphyseal overgrowth from chronic hyperaemia

View larger

View larger

Haematology first. The foundation is factor replacement or prophylaxis, led by the haematologist, to abolish recurrent bleeds and protect the target joint.

Synovectomy. For persistent bleeding despite prophylaxis, synovectomy reduces bleed frequency. Radiosynovectomy, an intra-articular radioactive isotope such as yttrium-90, rhenium-186 or phosphorus-32, is minimally invasive and first-line in many centres, a way to break the bleed-synovitis cycle before cartilage is lost. Surgical synovectomy, arthroscopic or open, is reserved for its failure.

End-stage disease. 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.

Global epidemiology:

• Symptomatic elbow arthritis affects under 1% of the population — far rarer than hip or knee disease
• Inflammatory (RA) and post-traumatic causes predominate worldwide; primary OA accounts for only a minority and is overrepresented in male manual workers and athletes
• TEA is a comparatively low-volume procedure globally (a few cases per surgeon per year), concentrated in specialist upper-limb units
• Falling RA disease burden in high-income settings (driven by early DMARD/biologic therapy) has shifted the dominant TEA indication toward acute distal humeral fracture and post-traumatic arthritis

Linked or unlinked TEA. Linked (semiconstrained) designs tolerate ligament deficiency and bone loss but transfer load to the cement-bone interface, risking loosening. Unlinked designs preserve bone but demand competent soft tissues and risk instability. No high-level trial establishes superiority, and the choice is patient- and surgeon-specific.

The young, high-demand patient. No durable solution exists for end-stage arthritis in active patients under 60. Debridement, interposition arthroplasty, arthrodesis, or accepting TEA with strict restrictions all carry significant trade-offs and limited evidence.

Triceps management in TEA. Triceps-reflecting, triceps-splitting and triceps-sparing (paratricipital) approaches each have advocates. Triceps insufficiency remains a recognised complication, and the optimal exposure to minimise it is unsettled.