Osteoarthritis of the elbow
Cause | Symptoms & pain | Diagnosis | Conservative treatment methods | Surgical treatment methods
Osteoarthritis is defined as the degradation of the joint cartilage. The joint components no longer glide smoothly against one another. As with the shoulder, there are many causes for osteoarthritis of the elbow.
By far the most common cause is accident. If a fracture occurs where the line of fracture passes through the joint, it often results in displacement. This leads to a "groove" (defect) or even to a tier within the joint cartilage. The two joint partners no longer fit each other, leading to abrasion of the cartilage. Especially in adolescents, a piece of the cartilage itself can break off during a fall - this is called osteochondritis dissecans (OCD). If the piece of cartilage is not displaced, you can be lucky and it will heal in place. However, if it has detached from the bed of cartilage, a cartilage defect develops there which will trigger osteoarthritis. The detached piece remains within the joint and can also cause disruptions and osteoarthritis as a so-called free joint body.
Luckily, rheumatic joint diseases can today be treated pharmaceutically; we therefore now see the later consequences only rarely, namely rheumatoid arthritis. True (seropositive) rheumatoid arthritis is a severe disease mediated by the immune cells of the inner lining of the joint, the synovium. The joint cartilage is not actually diseased, rather is a victim of the disease. Women are more frequently affected than men. The disease has no known cause, but there are indications it has plagued humans for thousands of years.
Osteoarthritis forms also exist that present similarly to rheumatism but that are not - seronegative arthritis. The main one is gout, a very common disease that has much to do with our lifestyle. High blood pressure, obesity, diabetes, alcohol and a high portion of meat in the diet favour the deposition of urate crystals in the joints. These act exactly like sand in the gears. Luckily, the elbow is affected in only 30% of patients with gout. Pseudogout has a similar effect, but is caused by other crystals, the pyrophosphates. Chronic bowel diseases or psoriasis can also involve the joints.
Bleeding into the joint, for example in haemophilia, can also trigger osteoarthritis.
One highly feared cause of joint destruction is infection. Once bacteria enter the joint they are very difficult to treat. Not only do the bacteria "hide" in the cartilage, but it is difficult to deliver antibiotics there as cartilage does not have its own blood supply. If antibiotics are delivered directly into the joint they cause considerable disruption to the cartilage. Hence joint infections often end with a joint replacement. Unfortunately, the immune-modulating medications used for rheumatoid arthritis can favour infections.
The symptoms of osteoarthritis can vary widely and it is always astounding how well patients can live with a nearly destroyed joint.
This is one of the main symptoms of osteoarthritis. As the layers of cartilage on the joint partners no longer glide smoothly, mobility is impaired and the joint becomes stiff. Under certain circumstances this can be accompanied by little pain, or a lot. Extension of the elbow is usually impaired first. If approx. 30° of extension are missing, the arm will be shorter compared to the other side. Everyday activity is impaired if the range of movement at the elbow is reduced to less than 100°.
Osteoarthritis leads to inflammation of the joint: arthritis. This can lead to the expression of all five typical signs of inflammation:
- Pain – what you know well from sunburn also applies to the joint: inflammation hurts.
- Swelling – the joint is swollen and there is often effusion in the joint. This also reduces mobility.
- Overheating – hence the term "inflammation". To manage the occurrence, the body expands the blood vessels to provide better perfusion. Hence the above symptoms.
- Reddening – this is also a consequence of the increased perfusion and often the most visible sign of inflammation.
- Loss of function: the above symptoms lead to an inability to use the joint properly.
When the osteoarthritis is advanced, it may be that the stabilising soft tissues, especially the internal and external ligaments, no longer provide adequate support and the joint becomes loose, on top of everything else.
A serious physician will always make time for you and question you about your symptoms. It is important to work out whether you are mostly impaired by pain or poor function. However, a lot of other information is also required for the correct diagnosis and treatment: What is your occupation, what sports do you play, what are your expectations, are there other diseases, accidents or other important factors, etc. It should not be forgotten that the discussion also helps us to get to know each other and build trust.
As the elbow joint is directly under the skin, a lot can be learned simply from looking at it. Added to this are palpation (feeling) of the joint and, possibly, the pain. The mobility must also be tested. It is also important to test the stability, which must be performed very carefully. Special tests are used for this: these provide information about the function of the joint. They can appear rather arbitrary, such as lifting a chair by its arm.
X-ray and MRI
The X-ray image shows us the situation of the bone in the joint and is the most important diagnostic factor in the elbow. Not only does it give us information on the individual bones, their positions relative to each other and to the axes, it also shows the osteoarthritic changes very clearly. This can be a ganglion cyst, calcifications, irregular joint surfaces or bone cysts.
MRI has the advantage that is able to image soft tissues around a joint clearly, as well as the joint cartilage. This is because it shows the water content in a tissue - this is high in cartilage. Even early changes can therefore be diagnosed and treated appropriately. This also helps to differentiate side effects from the actual osteoarthritis.
WHAT THERAPIES ARE AVAILABLE FOR OSTEOARTHRITIS OF THE ELBOW?
The forms of osteoarthritis are as varied as the therapies. Whenever possible, the aim is of course to resolve the underlying disease (e.g. rheumatoid arthritis) so that the osteoarthritis is then treated at the cause. Unfortunately this is not always so simple. Occasionally an underlying problem can be corrected, but the osteoarthritis remains. This article will not address these disease-specific treatments.
In principle there are always two treatment options.
When a joint hurts, the first thing we usually do automatically is immobilise it. An acute irritation can then heal and the symptoms improve. However, a joint should not be immobilised for long periods as it will otherwise stiffen. It is therefore important to keep performing daily activities, but in a way that spares the joint. Removing stress is a part of the protection. This is unfortunately often forgotten as soon as the acute pain passes. We are pleased with the improvement and immediately go and play tennis - and the pain returns at full strength. It is therefore often important to adapt everyday activities so that the joint is not overstressed again.
These are an important part of the initial treatment. Not only owing to the comfort of a pain-free existence, but also for treating the inflammation that is usually present. It is usually worthwhile to combat the pain thoroughly when it first arises. Fewer pain relievers are then used overall - it is easier to blow out a candle than a bonfire.
There are many types of pain relievers that can share, or have different, mechanisms of action. What they have in common is that patients react individually to pain relievers. It is therefore important to adjust and control these on a personal basis. The WHO has developed a management guideline for this.
Physiotherapy is an important ally in the fight against osteoarthritis as it works with two essential methods.
Firstly, physical measures help to combat the pain and restore well-being. These include cooling with ice, compression, electrical stimulation, heat, etc.
Secondly, physiotherapy employs therapeutic exercise methods. These help to restore function and go far beyond simple mobilisation. Stability, strength and motion sequences are also a part of the therapy.
In addition to the above measures, it may be necessary to infiltrate the joint. This usually happens with a mixture of cortisone and local anaesthetic injected into the joint. This is a simple and very effective method of soothing the joint. As cortisone remains in the joint and is not distributed throughout the body, it does not have the side effects of cortisone tablets taken over a longer period.
Joint arthroscopy of the elbow has made enormous progress. It is still a surgical challenge owing to the arm nerves and vessels in the vicinity, and it is important that the orthopaedic surgeon knows what they are doing. The major advantage of arthroscopy is that the joint need not be opened up. Scars and soft-tissue injuries are therefore decreased and the insight into the joint is significantly better. Most procedures can now be performed open, as well as arthroscopically. The osteoarthritis can then be treated when it concerns a single, small cartilage defect. "Micro-fracturing" can then be used to "clean up" the underlying bone and encourage it to form new cartilage. Advanced or generalised osteoarthritis cannot be healed, but its consequences can be reduced. For example, loose joint bodies can be removed during the arthroscopy and the joint cleaned with debridement. This often improves the symptoms for a long time. A stiff joint can also be made mobile by loosening the joint capsule arthroscopically.
If osteoarthritis affects the radius in isolation, for example as a consequence of a fracture of the head of the radius, it may be possible to treat the osteoarthritis by removing the head surgically. This is possible as the radius does not transmit power in the elbow joint.
Although not new, one interesting approach for treating osteoarthritis of the elbow is interposition. For this, a gliding surface is surgically implanted between the two degraded joint partners. Large tendons (for example, a part of the Achilles tendon) or the fascia lata (a tough band of tissue around the muscles of the thigh) can be used as gliding surfaces. Over time, these become fibrous tissue that acts as a gliding surface within the joint. The surgery is primarily performed in younger patients with severe, destructive osteoarthritis; thankfully it is used only rarely.
Viable prostheses have also been available for the elbow since around the 1980s. Development took a long time and was largely driven by the extraordinary Bernard F. Morrey (his son Mark is a regular instructor for the Basel Elbow Surgery Course). He had to overcome unusual challenges to develop his prosthesis as the forces that act on the elbow are both subtle and powerful at the same time. The prosthesis could only be used stably when it received special support from the upper arm. In contrast to most prostheses, the joint partners are firmly attached to each other. Nonetheless, this prosthesis cannot be equated with shoulder or hip prostheses: it can only bear a maximum of 5 kg. This means that the patient is already restricted in household activities; sport and physical labour are largely out of the question.
Joint fusion is the final option when nothing else has worked and the patient has constant pain. It is important to find the correct angle in which to fuse the elbow so that the patient can still do as much as possible with it. This angle depends on the function of the shoulder and wrist. It is usually between 90° and 110°. Arthrodesis is certainly a drastic procedure, but it is astounding how much a patient is still able to do.
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