Elbow Degenerative Conditions and Nerve Disorders
Robert L. Brochin, MD
Joseph F. Styron, MD, PhD, FAAOS
Jason C. Ho, MD
Dr. Brochin or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of DJ Orthopaedics. Dr. Styron or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Acumed, LLC, Axogen, and EXSOmed and serves as a paid consultant to or is an employee of Acumed, LLC, Axogen, and EXSOmed. Dr. Ho or an immediate family member serves as a paid consultant to or is an employee of Biedermann Motech.
ABSTRACT
There are several etiologies of elbow pain and stiff-ness, including but not limited to primary elbow osteoarthritis, posttraumatic elbow arthritis, and inflammatory arthropathies that affect the elbow. It is important for orthopaedic surgeons to review these etiologies and focus on treatment options and their appropriate application with a current review of the literature. An understanding of two nerve compression syndromes about the elbow, cubital tunnel and radial tunnel syndromes, is also important.
Keywords: cubital tunnel syndrome; elbow arthritis; rheumatoid arthritis; total elbow arthroplasty
Introduction
Elbow motion is necessary for upper extremity function and the ability to position the hand in space. Functional elbow range of motion (ROM) for activities of daily living has been classically defined to be a 100° functional arc, with a range of 30° to 130°, and 50° for both pronation and supination, with more recent data supporting flexion arcs of 130°, and up to 149° of flexion for certain activities.1 The elbow is a constrained synovial hinge joint. Because of this constraint, it is intolerant of trauma and has a high propensity for stiffness and degeneration. Conditions that may cause pain and limit the elbow’s functional ROM include primary elbow osteoarthritis, posttraumatic elbow arthritis, and inflammatory arthropathies, specifically rheumatoid arthritis.
Etiologies
Elbow arthritis is mostly caused by three etiologies: primary osteoarthritis, posttraumatic arthrosis, and inflammatory arthropathies. Primary elbow osteoarthritis is relatively rare, occurring in less than 2% of the population.2 It is generally accepted that strenuous manual labor is a significant predisposing factor, and weightlifters and throwing athletes are thought to be specifically predisposed.2 Biomechanical studies have shown more force is transmitted across the radiocapitellar joint than the ulnohumeral joint (55% versus 45%) with an applied axial load.3 Up to three times the weight of an individual can be transmitted across the humeroulnar and humeroradial joints with heavy labor.4
Previous elbow trauma is a known risk factor for the development of secondary posttraumatic elbow arthrosis. Prior studies have shown posttraumatic arthritis as high as 80% in distal humeral fractures at 12 years or more follow-up after open reduction and internal fixation, with other studies showing 35% to 45% with distal humeral fractures or fracture-dislocations than with isolated radial head (5%) and olecranon fractures (9%) at mean 19-year follow-up.5,6 For isolated proximal ulna fractures managed surgically, a preoperative Regan and Morrey type 3 coronoid process fracture and a postoperative joint surface incongruity of greater than 2 mm were found to be associated with the development of arthritis.7 Although few long-term studies exist, elbow fractures occurring in childhood are thought to predispose individuals to osteoarthritis because of deformities related to epiphyseal plate injury or incomplete reduction of fractures.
Rheumatoid arthritis is the most common inflammatory arthropathy that affects the elbow. The elbow is involved in the disease process of 20% to 65% of patients with rheumatoid arthritis.8 Unlike primary elbow osteoarthritis, elbow rheumatoid arthritis usually involves diffuse and symmetric joint space narrowing
and cartilage destruction.8 As the disease progresses to more advanced stages, joint destruction may lead to subluxation, dislocation, bony fragmentation, and ultimately joint ankylosis (Figure 1). The use of disease-modifying antirheumatic drugs for the management of rheumatoid arthritis has been shown to decrease the radiographic progression of joint destruction in patients with rheumatoid arthritis.9
and cartilage destruction.8 As the disease progresses to more advanced stages, joint destruction may lead to subluxation, dislocation, bony fragmentation, and ultimately joint ankylosis (Figure 1). The use of disease-modifying antirheumatic drugs for the management of rheumatoid arthritis has been shown to decrease the radiographic progression of joint destruction in patients with rheumatoid arthritis.9
Evaluation
When evaluating patients with elbow arthritis, a thorough history should be obtained because it may offer insight into the etiology of their elbow complaint (eg, previous trauma, rheumatologic history). Complete physical examination includes a thorough assessment of elbow ROM. Flexion/extension assessment is typically performed with the arm parallel to the floor and the hand in full supination. It is particularly important to assess where in the arc of motion pain occurs. Pain primarily at the extremes of ROM suggests impeding bone or tissue, which is more responsive to joint-preserving procedures. Pain that occurs throughout the flexion/extension arc, along with pain with resisted flexion/extension, is more likely indicative of articular cartilage destruction. Pronation/supination should also be assessed, although in most patients with primary elbow arthritis this will be preserved. A full upper extremity neurologic examination should be performed, with particular attention paid to the ulnar nerve because medial osteophytes at the cubital tunnel or a tight ulnar retinaculum may compress the nerve.
 Figure 1 A, AP and lateral elbow radiographs from a patient with early rheumatoid arthritis with symmetric joint space narrowing and cartilage destruction. B, AP and lateral elbow radiographs from a patient with advanced rheumatoid arthritis with complete joint destruction and dislocation. (Courtesy of Jason C. Ho, MD.) |
 Figure 2 Example of AP and lateral plain radiographs (A) and three-dimensional CT scan showing anterior and posterior views of the elbow (B) of a 38-year-old man who works as a laborer with primary elbow osteoarthritis demonstrating the mechanical blocks to elbow range of motion including osteophytes and loose bodies. (Courtesy of Jason C. Ho, MD.) |
Plain radiographs of the elbow are necessary at a minimum to evaluate the severity of the disease. CT scans can be particularly helpful in identifying areas of bony impingement if surgical intervention is considered. A 2021 study has shown that when compared to plain radiographs, elbow CT scans have greater sensitivity and higher interrater agreement in detecting osteophytes and loose bodies when correlating imaging findings with intraoperative findings10 (Figure 2). Nerve conduction studies can be considered to evaluate the severity of nerve impingement if neurologic symptoms are present.
Nonsurgical Treatment
In patients with preserved and functional arc of motion and relatively minor pain and disability related to the elbow, nonsurgical treatment is appropriate. The mainstays of nonsurgical treatment for elbow arthritis include activity modification and physical therapy to delay progression and maintain ROM, oral NSAIDs, and intra-articular injections such as corticosteroid for pain relief. There is limited evidence comparing the efficacy of the various nonsurgical treatment modalities, but some authors maintain that the most important aspect of nonsurgical treatment is activity modification to delay progression after explaining the natural history of the disease process.
Intra-articular injections other than corticosteroid, such as hyaluronic acid, have been described for elbow arthritis. Hyaluronic acid has not been found to be useful in the treatment of patients with posttraumatic elbow arthritis, with patients experiencing no beneficial effects at 6-month follow-up.11 Furthermore, hyaluronic acid is not FDA approved for the treatment of patients with elbow osteoarthritis, and its use would be off-label. Platelet-rich plasma has been proposed as treatment for patients with osteoarthritis of various joints; however, to the authors’ knowledge there has not been a study specifically looking at its efficacy in managing elbow osteoarthritis.
Surgical Treatment
Surgical treatment in patients with elbow arthritis should be reserved for those with moderate to severe pain and significant functional impediments. Surgery may be indicated for either pain and/or limited ROM, and surgical indications should be individualized. For example, a person whose occupation involves heavy labor may tolerate more limited ROM versus a high-level athlete.
When surgery is indicated, surgical options are based on the goals of the intervention and the severity of the disease process. Surgical options include both arthroscopic and open joint débridement and soft-tissue releases, interpositional arthroplasty, elbow arthroplasty, and elbow arthrodesis. Each procedure and its indications will be discussed in more detail in the next paragraphs.
Débridement, Synovectomy, Capsular Release, and Loose Body Removal
In patients in whom nonsurgical treatment has failed, the most common procedures attempt joint preservation because joint replacement surgeries are reserved for more advanced pathology or patients with limited activity goals. The goals of joint-preserving surgery include the removal of marginal osteophytes that impede elbow ROM and removal of loose bodies and may include anterior and posterior capsular release if joint contractures are present. Pathologic synovium and pannus resection can also be therapeutic in patients with
rheumatoid arthritis. At the time of surgery, the ulnar nerve is released or transposed if symptoms are present. Although data in the literature have been mixed, some authors have advocated a prophylactic ulnar nerve release even when preoperative ulnar nerve symptoms are not present if a significant flexion contracture exists, with the hypothesis that increased postoperative ROM would produce new-onset ulnar nerve compression symptoms.12,13
rheumatoid arthritis. At the time of surgery, the ulnar nerve is released or transposed if symptoms are present. Although data in the literature have been mixed, some authors have advocated a prophylactic ulnar nerve release even when preoperative ulnar nerve symptoms are not present if a significant flexion contracture exists, with the hypothesis that increased postoperative ROM would produce new-onset ulnar nerve compression symptoms.12,13
One study found that there was a higher rate of postoperative ulnar nerve symptoms in patients who underwent elbow contracture release without cubital tunnel release at the time of surgery if patient had preoperative flexion less than or equal to 100° compared with patients with preoperative flexion greater than or equal to 100°, although their results did not reach significance.12 These procedures may be performed arthroscopically or in an open fashion. Débridement is generally considered to be most reliable when peripheral osteophytes cause pain at terminal flexion and extension with limitation of motion, but the central portion of the joint is preserved.
Open Techniques
The classic open treatment for patients with mild to moderate elbow arthritis is the Outerbridge-Kashiwagi procedure, which involves a transhumeral approach via a triceps split with distal humeral fenestration to remove impinging osteophytes from the olecranon, coronoid, and their corresponding fossae. In the largest long-term follow-up study, this procedure was found to result in little or no pain in a little more than one-half of patients (55%).14 The addition of the release of the collateral ligaments to enable joint subluxation to assess the articular surface and allow for more extensive osteophyte excision has been termed débridement arthroplasty. Mean 5-year outcomes for this procedure have shown recurrence of mild arthritis, but with durable pain relief and improved ROM.15 A modified Outerbridge-Kashiwagi procedure has been described in which the triceps was elevated rather than split to access the olecranon and a trephine used to remove osteophytes encroaching on the olecranon and coronoid fossae. This modification was called ulnohumeral arthroplasty.16 At an average of 80 months, mean flexion/extension arc improved significantly from 79° to 101°, 76% of patients had no pain, and 75.5% of patients had excellent or good Mayo Elbow Performance Scores (MEPS).13 A medial column over-the-top approach, with or without a lateral column approach, has also been investigated specifically to treat posttraumatic elbow stiffness. These dual approaches have demonstrated an improvement in ROM at mean 1.5 years, although a relatively high rate of additional procedures was reported, including manipulation under anesthesia and subsequent revision contracture releases.17
Open synovectomy alone has been investigated in patients with rheumatoid arthritis. Long-term follow-up has demonstrated survivorship of synovectomy for rheumatoid arthritis after 10, 15, and 20 years at 97%, 75%, and 70%, respectively, with an overall recurrence of synovitis of 31%.18
Arthroscopic Techniques
Arthroscopic techniques for the management of elbow arthritis have been developed and are gaining favor. An arthroscopic procedure with three-dimensional reshaping of the bones of the elbow joint, removal of loose bodies, and capsulectomy has been described and is known as arthroscopic osteocapsular arthroplasty.19 This is a technically demanding procedure that involves four key steps: (1) establishing a view, (2) creating a space in which to work, (3) bone removal, and (4) capsulectomy (Figure 3). In this technique prior to osteocapsular arthroplasty the ulnar nerve is released through a limited posteromedial skin incision. Advocates of this procedure find that it provides comparable results to similar open procedures with quicker recovery and better cosmetic results.19 Other authors have compared arthroscopic débridement, with and without capsulectomy, and have shown greater improvement in ROM with capsulectomy without a difference in rate of complications.20 According to a 2019 study, no difference has been shown in efficacy of arthroscopic débridement in primary versus posttraumatic elbow arthritis, with improvement in pain, ROM, and functional score in both groups.21
Open Versus Arthroscopic Débridement
As arthroscopic débridement has become more popular, several authors have investigated whether a difference in outcomes exists when compared with open procedures. In a 2019 series from a single institution comparing 35 consecutive open débridements with 52 consecutive arthroscopic osteocapsular arthroplasties at a mean follow-up of approximately 3 years, both procedures demonstrated similar significant improvements in ROM, MEPS, and visual analog scale score.22 Both groups demonstrated inferior outcomes when preoperative ulnohumeral joint narrowing was measured at <2 mm. A 2020 systematic review of the literature found no difference in functional outcomes and similar improvements in ROM between open and arthroscopic procedures, leading to the conclusion that both are effective and reliable techniques.23
 Figure 3 Clinical images of an elbow arthroscopy. A, The anterior joint looking from lateral to medial with a coronoid spur (*) and its subsequent débridement and distal humeral osteoplasty (ˆ) (B). C, The posterior elbow joint with a large olecranon spur (**) and its subsequent débridement (D). (Courtesy of Jason C. Ho, MD.) |
Elbow Interposition Arthroplasty
In more advanced cases of primary or posttraumatic elbow arthritis where joint débridement may not reliably produce a satisfactory outcome, arthroplasty is usually considered. Débridement alone is unlikely to be reliable when there is pain throughout the arc of motion and radiographs/CT demonstrate extensive joint destruction with a loss of cartilage and narrowing of the entire joint space. Total elbow arthroplasty (TEA) will be discussed in the next paragraphs, but because of concerns with implant longevity in active patients other procedures have been developed that maintain the native bony architecture of the elbow while attempting to provide pain relief. A technique has been described in which the joint is exposed with a triceps-on technique, the joint is thoroughly débrided of osteophytes, and the humeral articulation is resurfaced with allograft such as fascia lata, Achilles tendon, or a similar synthetic substance.24 This procedure has been advocated in the setting of severe primary or posttraumatic elbow arthritis or stage II or IIA rheumatoid arthritis in young, high-demand patients. Other authors have found mixed results, with
fewer than one-half of patients having good or excellent results at mean 6-year follow-up with a high rate of revision, leading to the conclusion that this procedure should be reserved only for young, active patients who may not tolerate TEA.25 Some recent studies have reported more favorable results for posttraumatic and rheumatoid cases, with most patients having significantly improved MEPS and excellent or good results at short-term follow-up when performing interpositional arthroplasty as a salvage procedure in lieu of TEA26 (Figure 4).
fewer than one-half of patients having good or excellent results at mean 6-year follow-up with a high rate of revision, leading to the conclusion that this procedure should be reserved only for young, active patients who may not tolerate TEA.25 Some recent studies have reported more favorable results for posttraumatic and rheumatoid cases, with most patients having significantly improved MEPS and excellent or good results at short-term follow-up when performing interpositional arthroplasty as a salvage procedure in lieu of TEA26 (Figure 4).
Related posts:
Orthopaedic Patient Safety: Core Competencies and Communication Skills
New Technology in Orthopaedic Surgery: Robotics, Artificial Intelligence, and Machine Learning
Applications of Three-Dimensional Technologies in Orthopaedic Surgery
Shoulder Anatomy, Biomechanics, Clinical Evaluation, and Imaging
Ligament Injuries of the Wrist
Articular Cartilage of the Knee: Defects, Degeneration, and Preservation
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
