Download Information leafletArthritis of the elbow
What is it?
Arthritis is wear and tear of the joint. There are two main types of arthritis that can affect the elbow: 'Osteoarthritis'(Degeneration) and 'Inflammatory Arthritis' (or 'Rheumatoid Arthritis').
Osteoarthritis is a slow process that develops over many years. With this type of arthritis the joint cartilage gradually roughens and becomes thin. Small bits of cartilage may float around the joint and are known as loose bodies. The bone underneath thickens and the bone at the edge grows outwards causing bony spurs (osteophytes). The joint may swell as the body makes extra fluid to lubricate the joint. The joint may become deformed and there will be gradual loss of movement. In the elbow, the bony spurs and deformity may cause irritation of the ulnar nerve (see Ulnar Neuritis page and information leaflet).
Inflammatory Arthritis includes conditions like rheumatoid disease
What is its cause?
The most common cause of osteoarthritis is wear and tear of the joint due to ageing. This is called 'Primary Osteoarthritis'. Sometimes a major injury (fracture, dislocation) to the elbow joint, may lead to osteoarthritis in later life, and this is termed as ‘Secondary Osteoarthritis'.
In rheumatoid arthritis the arthritis spreads throughout the body. In this condition the patients' own immune system mistakenly attacks the joints causing damage to many joints in the body.
What are the symptoms and how is elbow arthritis diagnosed?
The symptoms of primary osteoarthritis start in middle age and start with gradually increasing pain and stiffness. Initially there is pain followed by difficulty to straighten the elbow. Later, bending the elbow completely becomes difficult. With time the symptoms will increase and cause significant functional disability. Other associated symptoms could be locking (as the loose bodies get caught in the joint); pins and needles in the hand (irritation of the ulnar nerve); grinding or crunching within the elbow and deformity.
The elbow can be damaged by rheumatoid arthritis at any age.
Will further tests or investigations be needed?
An x-ray of the elbow is needed (as above). The x-ray will confirm the extent and type of arthritis. No further tests are needed, but depending on the symptoms (locking) a MR or CT scan may be advised. Electrical tests (nerve conduction studies) may be advised if the patient has pins and needles in the hand.
What is the treatment?
- Initial conservative management consists of painkillers, anti-inflammatory medication and activity modification. This is aimed at easing the pain and regaining further range of motion.
- A steroid injection in the elbow may relieve symptoms. The injection very occasionally causes some thinning or colour change of the skin at the site. Improvement is variable and can be temporary.
- If the above measures fail, then surgery is considered. There are various operation possibilities. The type of surgery that will be recommended will depend on the nature and longevity of the symptoms, extent of arthritis, age and functional demands of the patient. The main operations are:
Arthroscopic (keyhole) surgery: A relatively small operation during which a telescope is passed into the elbow through one small incision (½ cm). Another 1 or 2 small stab incisions are made for access of instruments which remove loose bodies, inflammatory tissue and bony spurs.
Elbow debridement (OK procedure): This type of surgery is advised for marked arthritis that is causing significant loss of movement and pain. An incision of about 10cm is needed on the back of the elbow. At surgery all loose bodies and bony spurs that are blocking movement are removed. A fenestration is made in the distal humerus (end of the arm bone) and loose bodies or spurs in the front of the elbow are also removed. The elbow is put in a splint, in an extended position, at night only, for 2-3 weeks. Physiotherapy after surgery is critical.
Total elbow replacement: Joint replacement of the elbow is usually a successful operation. The pictures below show x-rays of the replacement in a patient who has rheumatoid arthritis. Replacement is usually avoided in young people but is a good option for patients with rheumatoid arthritis or those having low demands on the elbow. The operation will lead to significant pain relief and improved functional range of movement. The elbow in put in splint, in an extended position, at night only, for 2-3 weeks. Physiotherapy after surgery is critical.
What happens if it is not treated?
It is likely that with time, pain may lessen and a functional range of motion may be maintained. The symptoms may resolve to such an extent that the patient may be able cope with the residual lack of movement. However most patients will find symptoms will deteriorate with time, and they will need further treatment.
What is the success of surgical treatment?
Each of the surgical treatments is successful if they have been advised at an appropriate stage of the disease. Arthroscopic removal of loose bodies will nearly always stop symptoms such as locking. More than 80% patients will achieve a better range of movement and significant improvement in their pain after debridement of the elbow. In more than 95% of patients, the elbow replacement will lead to a pain free elbow with a good functional range of movement.
It must be borne in mind that osteoarthritis is a slowly progressive condition. It is hence possible that with time the symptoms may return after either arthroscopic surgery or elbow debridement, as the osteoarthritis progresses.
What are the complications of surgical treatment?
- The surgical scar may be tender for a few weeks but will nearly always settle. There is a small possibility that the scar may remain unattractive. An area of numbness can occur around the scar but this does not cause any problems.
- A degree of aching may persist in the elbow, after elbow debridement. This will depend on the extent of arthritis that was present at the time of surgery.
- Infection of the wound is possible but can usually be successfully treated with antibiotics. Very rarely infection may spread into the joint replacement.
- Injury to the nerve (ulnar nerve) can occur. This may lead to altered sensations such as tingling in the little finger and ring finger. If this nerve is damaged it may lead to significant pain, sensory or motor loss. It is important that the nerve is cared for at the time of surgery.
- In the long term, the elbow joint replacement may fail and will need to be revised. However, it is expected that nearly 90% of elbow replacements will still be successful after 10 years, in low demand patients.
- Severe complex regional pain syndrome (CRPS) is a rare but serious complication after surgery. Unfortunately it is not possible to predict this problem but it needs to be monitored and treated (usually just with physiotherapy) if it develops.
- Any surgical intervention has the risk of developing complications / setbacks which are unpredicted. These complications may have the potential to leave the patient worse than before surgery.
Is there anything I can do to improve the outcome?
- Keep the wounds dry and clean until they have healed.
- After the operation, the therapist will see you to start exercising of the elbow. It is important to do the prescribed exercises regularly both during the physiotherapy sessions and at home. It will help to keep the pain levels down with analgesics, so as to keep your elbow moving.
- It is advised not to wear rings on the operated side for 4-6 weeks after surgery.
When can I do various activities?
Return to work depends on many factors including the nature of the job and hand dominance.
- Following arthroscopic surgery, patients should be able to return to a desk job within 7 days.
- Following elbow debridement or replacement, patients should be able to return to a desk job within 4-6 weeks of the operation and perform reasonable tasks with the limb by that time.
- Manual work after surgery should be avoided for 8-12 weeks.
- Manual work is not recommended after an elbow replacement.
- Driving should be possible within 1-2 weeks of keyhole surgery, and 4 – 6 weeks following other surgery. Before driving, do check that you can manage all controls and start with short journeys.
