Elbow osteoarthritis

How does elbow osteoarthritis develop?

Osteoarthritis refers to the wear and tear of the joint cartilage. As a result, the joint partners no longer slide smoothly against each other. As with the shoulder, there are many causes of osteoarthritis in the elbow:

Bone fracture

By far the most common cause is an accident. If there is a bone fracture where the fracture line passes through the joint, it is often displaced. This creates a "trench" (defect) or even a step in the joint cartilage. As a result, the two joint partners are no longer aligned and the cartilage is worn away. In young people in particular, a piece of cartilage can break off during a fall, a so-called osteochondrosis dissecans (OCD). If the piece of cartilage is not displaced, you may be lucky and it will heal again. However, if it has become detached from its cartilage bed, there is a cartilage defect in the same place and this will cause osteoarthritis. The broken piece remains in the joint and can also interfere as a foreign body, a so-called joint mouse, and cause osteoarthritis.

Rheumatoid arthritis

Fortunately, rheumatic joint diseases can now be treated with medication. As a result, the late effects, namely rheumatoid arthritis, are now rare. True (seropositive) rheumatism is a serious disease that is caused by immune cells from the synovial membrane, the inner lining of the joint. The joint cartilage is therefore not actually diseased, but a victim of the disease. Women are more frequently affected than men. There is no known cause for the disease, but there is evidence that it has plagued mankind for many thousands of years.

Arthritis

However, there are also arthroses that look like rheumatism but are not: seronegative arthritis; above all gout, a fairly common disease that has something to do with our lifestyle. High blood pressure, obesity, diabetes, alcohol and lots of meat favour the deposition of urate crystals in the joints. There they literally act like sand in the gears. Fortunately, the elbow is only affected in around 30 per cent of all gout patients. Pseudogout has the same effect, but uses other crystals, the pyrophosphates. Chronic intestinal diseases or psoriasis can also cause joint involvement.

Haemorrhages

Haemorrhages in the joint, for example in haemophilia, can also trigger osteoarthritis.

Infections

A very feared cause of joint destruction is infection. If bacteria get into the joint, they are very difficult to treat. Not only do the bacteria "hide" in the cartilage, but the antibiotics have difficulty getting there because the cartilage has no blood supply of its own. If the antibiotics are administered directly into the joint, they in turn cause considerable damage to the cartilage. This is why joint infections often end in joint replacement. Unfortunately, it is precisely the immunomodulating drugs used in rheumatoid arthritis that can favour infections.

Which complaints occur frequently?

The symptoms of osteoarthritis can vary greatly, and it is always amazing how well patients can live with an almost destroyed joint.

Joint stiffness

This is one of the main symptoms of osteoarthritis. Because the cartilage layer of the joint partners no longer glides smoothly, mobility becomes more difficult and the joint becomes stiff. This can happen with little pain or can be very painful. The stretching of the elbow is usually affected first. If there is a lack of about 30 degrees of extension, the arm becomes too short compared to the opposite side. If the range of motion at the elbow is reduced to less than 100 degrees, everyday life is impaired.

Inflammation

Osteoarthritis leads to inflammation, or arthritis, in the joint. This can express all five typical signs of inflammation:

• Pain: What you know best from sunburn also applies to the joint: the inflammation hurts.
• Swelling: The joint is swollen and there is often an effusion in the joint. This also reduces mobility.
• Overheating: This is why the term inflammation is used. In order to deal with this, the body dilates the blood vessels to improve blood flow. This results in the above symptoms.
• Redness: This is also a result of increased blood flow and is often the most visible sign of inflammation.
• Loss of function: The above symptoms mean that the joint can no longer be used normally.

Instability

It is only when osteoarthritis has progressed that the stabilising soft tissues, in particular the ligaments on the inside and outside, may no longer provide sufficient support and, in addition to everything else, a perpendicular joint may develop.

How is elbow osteoarthritis diagnosed?

As always with a reputable doctor, they will first take time for you and enquire about your complaints. It is important to work out whether you are primarily affected by pain or poor function. But there is a lot more information that is needed for a correct diagnosis and treatment: What do you do for work, what sport do you do, what expectations do you have, are there any other illnesses, accidents or other important factors, etc.? It is important to remember that the consultation is also about getting to know each other and building mutual trust.

Because the elbow joint lies directly under the skin, a lot can be determined just by looking at it. In addition, the joint and any pain can be felt. Mobility must also be checked. It is also important to check the stability, which must be done very carefully. And then special tests are used to provide information about the function of the joint. They can be quite idiosyncratic, such as lifting a chair by the backrest.

X-ray and MRI

The X-ray shows the situation of the bone in the joint and is the most important diagnostic tool for the elbow. Not only does it provide information on the individual bones, their position in relation to each other and the axes, but it also clearly shows osteoarthritic changes. These can be an overbone, calcifications, irregular joint surfaces or bone cysts.

MRI has the great advantage that it can image the soft tissue around a joint as well as the articular cartilage. This is because it shows the water content of the tissue, which is high in cartilage. This means that early changes can be diagnosed and treated accordingly. And in some cases, it can be used to distinguish accompanying symptoms from the actual osteoarthritis.

How is elbow osteoarthritis treated?

The therapies for osteoarthritis are just as varied as the different forms of osteoarthritis. Whenever possible, one would naturally like to eliminate the underlying disease (e.g. rheumatism) so that the osteoarthritis is treated at its cause. Unfortunately, this is often not so easy. And sometimes the underlying problem is resolved, but the osteoarthritis remains. These disease-specific treatments are not discussed here.

There are always two basic treatment options:

Conservative treatment methods

The first thing you usually do automatically when a joint hurts is to immobilise it. This allows an acute irritation to heal and the symptoms to improve. However, a joint should not be immobilised for a long period of time, as otherwise it will become stiff. It is therefore important to continue to carry out everyday activities, but in such a way that the joint is protected. Relief is part of the protection. Unfortunately, it is often forgotten as soon as acute pain subsides. People are happy about the improvement and immediately go back to playing tennis - and the pain returns undiminished. It is therefore often important to adjust your daily routine so that you don't overload the joint again.

Painkillers

They are an important part of the initial treatment. Not only because of the comfort of a pain-free existence, but also to combat the inflammation that is usually present. It usually makes sense to combat pain thoroughly as soon as it arises. You then often need fewer painkillers overall - it is easier to extinguish a small flame than a large fire.

There are many different painkillers, some of which have the same effect and some of which have very different effects. What they have in common is that patients react very individually to painkillers. It is therefore important to personalise and monitor them. The WHO has developed a step-by-step scheme for this purpose.

Physiotherapy

Physiotherapy is an important ally in the fight against osteoarthritis because it works with two methods, both of which are essential:

Firstly, with physical measures that help to combat pain and restore well-being. These include, for example, cooling with ice, compression, stimulation current, heat and so on.

On the other hand, physiotherapy works with the means of physiotherapy. This helps to restore function and goes far beyond simple mobilisation. Stability, strength and movement are also part of the therapy.

Infiltrations

In addition to the above measures, it may be necessary to infiltrate a joint. This is usually done with a mixture of cortisone and local anaesthetic, which is injected into the joint. This is a simple and very effective method of soothing a joint. Because the cortisone remains in the joint and does not spread throughout the body, it does not have the side effects of cortisone tablets taken over a long period of time.

Surgical treatment methods

Arthroscopy

Arthroscopy of the elbow has made enormous progress. However, it is still a surgical challenge due to the arm nerves and nearby blood vessels, and it is important that your orthopaedic surgeon knows exactly what he is doing. The great advantage of endoscopy is that the joint does not have to be opened. This minimises scarring and soft tissue damage, and the overview of the joint is much better. Most operations today can be performed both open and arthroscopically. Osteoarthritis can be treated if it is a single small cartilage defect. The underlying bone can then be "freshened up" with a so-called microfracturing procedure, causing it to form replacement cartilage. Advanced or generalised osteoarthritis cannot be cured, but its consequences can be alleviated. For example, loose joint bodies can be removed with arthroscopy and the joint can be cleaned with debridement. This often improves the symptoms for a long time. In addition, a stiff joint can be made mobile by loosening the joint capsule arthroscopically.

Resection

If osteoarthritis affects the radius in isolation, for example as a result of a fracture of the radial head, it is possible to surgically remove this head and thus treat the osteoarthritis. This is possible because the radius at the elbow is not a load-bearing joint.

Interposition

An interesting, albeit not new, approach to treating osteoarthritis of the elbow is interposition. This involves surgically inserting a gliding layer between the two worn joint partners. Large tendons (for example parts of the Achilles tendon) or the fascia lata, a rough fascia on the thigh, are used as a gliding layer. Over time, they transform into a fibrous tissue that acts as a gliding layer in the joint. This operation is mainly used in young patients with severe, destructive osteoarthritis and is fortunately very rare.

Elbow prosthesis

Viable prostheses have also been available for the elbow since around the 1980s. Their development took a very long time and was driven forward primarily by the extraordinary Bernard F. Morrey (his son Mark is a regular instructor at the Basel Elbow Surgery Course). Morrey had to overcome unusual challenges in the development of his prosthesis, as the forces acting on the elbow are both subtle and enormous. For this reason, the prosthesis was only stable and usable when it was given special support on the upper arm and, unlike most prostheses, the joint partners were firmly connected to each other. Nevertheless, this prosthesis is not the same as a shoulder or even a hip prosthesis, as it can only bear a maximum load of 5 kg. This means that you are already quite restricted in the household, and sport or physical work is almost unthinkable.

Arthrodesis

Joint fusion is the last option when nothing else works, but the patient is always in pain. It is important to find the right angle for the elbow fusion so that the patient can still do as much as possible. This angle depends on the function of the shoulder and wrist. It is usually between 90 and 110 degrees. Arthrodesis is certainly a very incisive procedure, but patients are sometimes amazed at what they can still do afterwards.

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