Shoulder & Elbow.

ISSN 1758-5732

REVIEW ARTICLE

Primary elbow osteoarthritis: an updated review

Deepthi Nandan Adla & David Stanley Department of Orthopaedics, Northern General Hospital, Shefeld, UK Department of Orthopaedics, STH Foundation Trust, Shefeld, UK
ABSTRACT
Received Received 30 April 2010; accepted 16 July 2010 Keywords Primary osteoarthritis, elbow, aetiology, natural history, management, open surgery and arthroscopy, arthroplasty Conicts of Interest None declared Correspondence David Stanley, Department of Orthopaedics, Northern General Hospital, Shefeld, South Yorkshire, S5 7AU, UK. Tel.: +44 (0)114 2714025. Fax: +44 (0)114 2266796. E-mail: claire.faulkner@sth.nhs.uk DOI:10.1111/j.1758-5740.2010.00089.x

Primary elbow arthritis predominantly affects middle aged men undertaking heavy manual work. Patients present with pain and limited movement but may also complain of ulnar nerve sensory or motor symptoms. Radiographic features include osteophytes at the tip of the olecranon and coronoid processes, loose bodies, narrowing of the radiocapitellar joint space and thickening of the olecranon fossa membrane. Treatment options range from conservative management using oral analgaesics and non-steroidal antiinammatory drugs through to open debridement procedures, arthroscopy and occasionaly in selected patients total elbow arthroplasty.

INTRODUCTION Primary osteoarthritis (OA) of the elbow is a relatively uncommon condition mainly affecting middle aged men. It accounts for 1% to 2% of patients presenting with all types of elbow arthritis [1]. In a specialist rheumatology practice, Doherty and Preston identied 16 patients (7%) with elbow osteoarthritis from 225 referrals with nonnodal large joint osteoarthritis [2]. Previous reports on elbow OA have not commented on associated involvement at other sites but, in this series, 71% of men had associated metacarpophalangeal joint OA. As with the elbow, the metacarpophalangeal joint is often considered an uncommon site for OA. It has been suggested that this association occurs principally in those undertaking heavy manual work (Missouri metacarpal syndrome) [2,3]. In a study assessing 1000 consecutive fracture clinic patients, the prevalence of symptomatic elbow osteoarthritis was noted to be 2%. The condition was rarely seen in patients below 40 years of age and was very uncommon in women [4]. AETIOLOGY The aetiology of primary elbow OA is still unclear, although combinations of environmental and genetic factors have been implicated. In particular, there are a number of studies that have suggested heavy and repetitive work to be important factors. Elbow osteoarthritis was noted in 32.8% of 744 German coal miners who used pneumatic boring hammers on a regular basis [5]. A later study by Hunter et al. assessed 286 pneumatic tool workers, and noted elbow OA in 10.5%. The authors concluded, however, that there was no convincing evidence for this being

caused by pneumatic tools. They also noted that there was no increase in frequency of OA in patients using tools with higher vibration frequencies [6]. Lawrence showed no statistical signicant difference in the incidence of elbow OA in coal miners who used pneumatic drills for 1 year (31%) compared to those who did not use this equipment (16%). He concluded that the development of elbow arthritis was a feature of most types of heavy manual work that he investigated [7]. More recently, a signicant doseeffect relationship to the range of exion and radiographic changes in the dominant elbow, which was independent of age, was noted in a study of 74 male stone quarry workers who operated chipping hammers and rock drills [8]. Heavy nondrilling work has also been reported to be associated with elbow OA. It has not been reported in light manual ofce based workers, although it was noticed more commonly in heavy coalmine workers [7,9]. A study from Shefeld showed the prevalence of elbow OA to be 10.5% in heavy workers compared to 2.2% in nonheavy workers, with the dominant arm more frequently affected. The condition is also recognized in patients with ambulatory problems, requiring the use of crutches. In this group, the dominant extremity is involved in approximately 80% to 90% of patients [10]. All these ndings suggest that excessive loading of the elbow is an important predisposing factor. The part played by genetic factors in elbow OA is less clear, although demographic studies have shown differences in the incidence of the condition in different races. A positive family history was not noted in patients with symptomatic elbow OA [4]. 41

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Table 1 Classication of primary elbow osteoarthritis Symptoms Mild Intermittent acute pain. Pain mostly on extension Signs Posterior tenderness, Pain on passive elbow extension sign of posterior impingement ROM: near normal, but may have xed exion deformity of less than 30 . Flexion is usually normal Tender posteriorly and sometimes anteriorly. Crepitus on gripping and forearm rotation ROM: 30 to 120 Generalized joint tenderness Crepitus and pain throughout ROM ROM: 50 to 110 Radiographic ndings Small osteophytes on tip of olecranon and or coranoid

Moderate

Pain worse with activities Locking of joint Deteriorating ROM Constant pain requiring regular analgesia Pain throughout ROM Stiffness and crepitus

Obvious osteophytes Joint line preserved Olecranon and coronoid fossae thickened Obvious osteophytes Joint line narrowed Loss of the outline of olecranon and Coranoid fossae

Severe

ROM, range of motion.

NATURAL HISTORY AND CHANGES IN ELBOW OSTEOARTHRITIS Goodfellow and Bullough studied the age related changes in the elbow joint in 28 cadavers. They noticed a certain pattern of degeneration and wear in the radiohumeral joint which was considered to be the result of a combination of rotation and hinge movements. By contrast, the ulnohumeral articulation, which has hingemovementonly,showedonlyminorlinearwearchanges [11]. Age-related changes appear to start on the radial aspect of the elbow and gradually progress to the ulnohumeral joint, as a result of excessive load concentrations occurring at the centre of the joint. These ndings were conrmed in another cadaveric study [12] and similar intra-operative observations have been recorded [13,14]. More recently, a casecontrol study comparing radiographic changes at the elbow joint in patients with elbow osteoarthritis with age- and sex-matched individuals showed that joint nar rowing at the radiocapitellar joint was the third most common nding in OA patients. The changes in the osteoarthritis group were predominantly of osteophyte formation, involving the olecranon, coronoid and radial head in descending order. The classic features of osteoarthritis with joint space narrowing and cyst formation are late and uncommon ndings in the elbow. Loose bodies and thickening of the olecrenon fossa membrane were also frequently noted [15]. A histopathological study of the elbow conrmed thickening of all components of olecranon fossa membrane (anterior cortical bone, medullary cavity, posterior cortical bone, and anterior and posterior brous tissue) in patients with osteoarthritis of the elbow compared to a control group [16]. The histological and radiographic changes in the osteoarthritic elbow help to explain the pattern of presentation, which is predominantly related to impingement and loose body formation, causing mechanical symptoms. 42

Clinical presentation The usual mode of presentation is pain, reduced movement and locking. The clinical presentation can be broadly classied as mechanical, which may be in mild, moderate, severe stages (Table 1), or neurological from ulnar neuropathy. Mild Patients with mild disease most frequently present with dull aching pain in the elbow with intermittent episodes of acute pain. Patients frequently have a near normal range of motion (ROM), although, when a decit is present, it is usually a xed exion deformity of less than 30 . There may be early ulnohumeral impingement as a result of osteophytes at the tip of the olecranon and coranoid, with pain on terminal extension and tenderness in the paraolecranon fossae (Fig. 1). Moderate In this stage, there is a progressive deterioration of ROM, with episodes of locking and acute pain. The pain is worse with activities that require heavy lifting or extension of the elbow. Patients often describe, locking of the joint, which requires trick movements to unlock the elbow, and usually indicating the presence of a loose body [17]. On clinical examination, the elbow may be swollen, with tenderness over the posterior and anterior aspects. A reduction in ROM to less than 30 of full extension to 120 exion is often present. Crepitus may be palpable on gripping and forearm rotation, indicating degeneration of the radiocapitellar joint. The symptoms at this stage are a result of osteophytes and loose bodies, which can be conrmed by plain radiographs (Fig. 2). Severe In severe disease, there is signicant reduction in the ROM and the pain is more constant. Patients usually require regular analgesia

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Fig. 1 Patient initially underwent a tennis elbow release, but represented with pain on extending the elbow and with signs of posterior impingement (mild osteoarthritis). Plain radiographs show heterotropic bone formation at the surgical site but a computed tomography scan with elbow in extension shows posterior impingement.

and signicant night pain may be a feature. On examination, there is reduction in the ROM to 50 to 110 of exion, and crepitus throughout the ROM is frequently noted. Reduction in joint space and osteophytes are seen on plain radiographs (Fig. 3). Ulnar neuropathy Ulnar nerve irritation is commonly observed in patients with elbow OA. Reduced sensation in the ulnar nerve distribution and weakness may be the sole presenting symptoms. Kashiwagi reported an incidence of 40.3% in patients with elbow OA [18] and a Japanese study on cubital tunnel syndrome noted evidence of elbow OA > 30% of patients [19]. A recent case series of elbow arthritis reported ulnar nerve irritation to be as high as 84% [20]. The irritation/entrapment is considered to be a result of osteophytes or other space occupying lesions such as ganglions arising from the elbow joint. A prevalence of 3% to 8% of medial elbow ganglia as a cause of ulnar nerve compression has been reported in patients presenting with cubital tunnel syndrome. This was the third most common cause of ulnar nerve compression [21,22]. A rapid onset of ulnar nerve symptoms should raise the suspicion of a ganglion and further imaging is appropriate before surgery [22]. Investigations Imaging modalities are used to conrm the diagnosis of elbow OA and electrophysiological tests for assessing ulnar nerve function. A standard plain radiograph of the elbow (anteroposterior and lateral views) is sufcient to diagnose most cases of elbow OA. The anteroposterior radiograph helps to assess the overall alignment of the joint, ulnohumeral joint line, radiocapitellar joint line and

Fig. 2 Patient with moderate elbow osteoarthritis. Plain radiographs show the osteophytes and the computed tomography scan shows a thickened olecranon membrane.

radial head osteophytes. It also shows the loss of outline of the olecranon fossa (indicating thickening of the membrane). Kashiwagi advocated a special radiographic view to assess the fossa. This is performed with the elbow exed to 60 and the distal arm placed at over the X-ray plate [18] (Fig. 4). The lateral radiograph is useful in assessing osteophytes at the tip of the olecranon and coronoid process, the ulnohumeral articulation and loose bodies. A recent radiographic study showed that the most common features in elbow OA were olecranon osteophytes (96%), followed by osteophytes of the coronoid process (90%), radial head (86%) and coronoid and radial fossae (64%) [15]. A more recent three-dimensional computed tomography (CT) scan study of 22 patients with elbow OA, to map the osteophyte distribution conrmed that, in 95% of patients, the osteophytes involved the ulnohumeral joint, whereas radiohumeral osteophytes were only found in 59%. Although cadaveric and biomechanical studies show that the radiohumeral joint is more prone to wear, the ulnohumeral joint is more markedly affected by osteophytes [23]. Loose bodies are a common cause for locking and they can mostly be identied on a plain radiograph. Ward et al. reported a sensitivity of 79%, a specicity of 69% and a diagnostic accuracy of 75% for plain radiography of loose bodies in the elbow [24]. A more recent comparison of plain radiography with arthroscopy yielded a sensitivity of 84% and a specicity of 71%. Plain 43

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Fig. 4 Kashiwagi view: anteroposterior view of elbow taken with the elbow exed to 60 and arm resting at on the plate. The olecranon fossa is clearly demonstrated.

Fig. 3 Patient with severe elbow osteoarthritis, with joint space narrowing.

radiography had a similar sensitivity and specicity to CT arthrography and magnetic resonance imaging (MRI) (overall sensitivity for the detection of loose bodies in either compartment was 88% to 100% with a specicity 20% to 70%) [25]. Correlating the clinical symptoms and signs with the radigraphic features is helpful in planning treatment because mild and moderate stage disease can be managed by debridement procedures. In early stage OA, the radiographs may show small osteophytes on the tip of olecranon or coranoid with thickening of the olecranon fossa membrane (Fig. 1). In moderate stage OA, the osteophytes are more obvious, although the joint line remains well preserved (Fig. 2). In severe stages of OA, there is a clear reduction in the joint space, which initially affects the radiocapitellar joint and, subsequently, the ulnohumeral articulations (Fig. 3). CT scans of the elbow with three-dimensional reconstructions help visualize shelf osteophytes, in the olecranon, radial and 44

the coronoid fossae. CT scanning with the elbow in maximal extension identies impingement of the tip of the olecranon on the membrane of the fossa. The relationship of osteophytes to the ulnar nerve is important with respect to surgical planning [26]. Both MRI and CT arthrography have excellent sensitivity (92% to 100%) but low to moderate specicity (15% to 77%) for identifying posteriorly-based loose bodies. Neither MRI, nor CT arthrography is consistently sensitive (46% to 91%) or specic (13% to 73%) in predicting the presence or absence of loose bodies anteriorly. In view of the invasive nature of CT arthrography, MRI is preferable [25]. In addition, MRI is of help in diagnosing noncalcied loose bodies and assessing the articular carilage [27]. Ultrasound examination of the ulnar nerve is a well recognized technique for assessing the thickness of the nerve, site of compression and presence of other lesions such as ganglions. TREATMENT Non-operative Once the diagnosis is made, patients should receive an explanation as to the cause of the symptoms and adviced on the natural history. Symptomatic treatment, aiming to control pain, is the rst line of management. This is more appropriate for patients with mild stage disease, who have no signicant limitation of activities of daily living or work. The main stay of initial treatment is analgesics and anti-inammatory medication. In the event of failure of this approach, consideration may be given to the use of steroid/viscosupplement injections. This is based solely on the

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practice of using this technique in other joints. We are unaware of any studies showing it to be of benet in the elbow joint. A recent case series of 19 patients with post-traumatic elbow OA, who received three intra-articular sodium hyaluronate injections at regular intervals over 4 weeks, showed minimal improvement in pain at 3 months, and no improvement at 6 months [28]. Operative treatment Several surgical treatments can be considered when non-operative measures fail to control symptoms. These can be divided into open or arthroscopic techniques, all of which aim to reduce pain and achieve some improvement in ROM. The decision on the choice of method depends on the stage of presentation and the surgeons skill and the familiarity with the different techniques. Open techniques Posterior approach (ulnohumeral arthroplasty). The OuterbridgeKashiwagi procedure was rst described by Kashiwagi in 1978 [18,29]. The procedure is performed through a posterior triceps splitting approach with fenestration of the olecranon fossa (1 cm to 1.5 cm) being performed to gain access to the anterior aspect of the elbow. The osteophytes on the olecranon and the coronoid process are excised (Minami and Ishii, 1986). Morrey modied the procedure and described the use of a trephine to fenestrate the olecranon fossa. He followed up 15 patients over a mean of 33 months and reported excellent results in 87% [30]. The results of ulnohumeral arthroplasty have been reported in several studies and are summarized in Table 2. Some of the patients reported by Antuna et al. also had an anterior capsular release through the fenestration or by a column procedure [14]. Long-term results of ulnohumeral arthroplasty have remained encouraging. Minami et al. reviewed the results of this arthroplasty in 44 elbows followed for 8 years to 16 years. They reported 61% patients had slight or no pain at nal review but noted 10% deterioration in ROM, when the same group was compared at 5 years and 12 years after initial surgery [36]. Complications. Complications that have been reported following open ulnohumeral arthroplasty include ulnar nerve entrapment, ulna nerve neuropraxia/irritation [14,37], anterior interosseous Table 2 Open ulnohumerl arthroplasty

nerve palsy [35], supercial wound infection, hematoma [37], myositis ossicans and triceps rupture [35]. A reoperation rate of 8% has also been reported [37]. Despite clinical success, radiographic signs of recurrence in the fenestrated area at the olecranon and coronoid fossae are know to occur. The rate of this recurrence increases with time. Wada et al. found recurrence of osteophytes in both the olecranon and the coronoid fossae in 100% of patients followed for 10 years or more. A correlation between radiographic signs of recurrence and functional outcome has not been rmly established. However, the slow reformation oftheolecranon fossamembraneandosteophytesthat hasbeen notedmayexplain thedelayin recurrenceofimpingement symptoms despite obvious radiographic changes [20,36,38]. Prognostic factors to predict the outcomes of ulnohumeral debridement have been suggested. Duration of symptoms of less than 2 years, pain scores of 2 or 3 (no pain, 0; occasional or mild pain, 1; regular pain requiring analgesia, 2; severe pain not relieved by analgesia, 3), and the presence of cubital tunnel syndrome were associated with an increased chance of a good outcome. The absence of pre-operative locking was associated with an increased chance of a poor outcome, although a history of trauma, the pre-operative ROM and number of loose bodies did not affect the outcome [37]. Posteromedial approach. Wada et al. described a posteromedial approach for debridement of the arthritic elbow. They reported the results in 32 patients, with a mean duration of follow-up of 121 months, of which 19 elbows were followed for more than 10 years. Twenty-eight (85%) patients reported no pain and ve had mild pain. The mean arc of movement improved by 24 . The mean Japanese Orthopaedic Association elbow score improved by 23 points. Of 25 patients who had performed heavy manual work, 76% returned to their previous job or an equivalent job. In the elbows followed for more than 10 years, the limitation of extension had increased by 7 with no change in exion. The loss of extension was attributed to the recurrence of osteophytes at the olecranon process (47%) and the olecranon fossa (47%). Wada advocated this approach for patients with degenerative arthritis who also had ulnar nerve symptoms requiring decompression [20].

Reference Forster et al. [38] Antuna et al. [14] Phillips et al. [32] Sarris et al. [33] Allen et al. [34] Vingerhoeds et al. [35] Hearnden et al. [36]

Number Primary Mean Follow-up Improvement Satisfaction MEPS (good- Complication Reoperation Year of elbows OA% age (months) in ROM (subjective) excellent) rate rate 2001 2002 2003 2004 2004 2004 2009 36 46 20 17 9 16 59 65 100 100 95 89 67 57 48 51.4 52 45 63 39 80 75 36 26 20 92 25 20 20 32 21 20 18 81% 74% 86.6% 63% 74% 65% 87.5% 60% 17% 11% 24% 8% 3.3%

OA, osteoarthritis; MEPS, Mayo Elbow Performance Score; ROM, range of motion.
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Posterolateral approach. Tsuge and Mizuseki described an extensive debridement arthroplasty though a posterolateral approach in 29 elbows, with an average follow-up of 5 years. The ulnar nerve was decompressed, the triceps and periosteum of the olecranon reected, and the joint dislocated by dividing the lateral collateral ligament. Pain was relieved in all cases, although some patients complained of dull aching on rm gripping. Impingement in exion and extension was noted at 5 years and most patients returned to their former occupation [13]. Oka et al. compared patients who had a lateral (20 patients), medial (10 patients) and a combined medial and lateral approaches (eight patients) over a mean of 5.9 years. No signicant differences in the outcomes were noted between the groups [39]. Arthroscopic techniques. Arthroscopy of the elbow has evolved with the advances in arthroscopic equipment and surgical techniques. It has become a more popular, safer and more effective treatment option for many elbow problems. Arthroscopic debridement of osteophytes and removal of loose bodies alone has shown promising results [40]. Arthroscopic modication of the OuterbridgeKashiwagi procedure has also been described. This procedure involves arthroscopic excision of the osteophytes and fenestration of the olecranon fossa. A study of 12 patients who underwent this procedure reported improvement in symptoms in all patients, although signicant improvements in ROM was not noted [41]. Inclusion of anterior and posterior capsular releases has been suggested to improve the ROM in the elbow [42]. Some studies have also included excision of the radial head [43,44]. Cohen et al. compared the results of arthroscopic (20) and open (15) debridement for primary OA of the elbow. Both procedures were surgically effective but no difference was noted in the patient perceived benet between the two groups, although the range of exion was slightly better in the open group at mean follow-up of 35.3 months [45]. More recent studies of arthroscopic debridement have shown some improvement in the ROM (Table 3). One study by Krishnan et al. has reported far greater improvement in ROM than the other arthroscopic studies and the published data from open procedures [46]. This study is of interest because the mean age of the patients was younger (36 years as opposed to >50 years) and therefore may not reect the outcome that can be expected in the more usual older aged patient with this condition. Debate remains as to whether radial head excision should be combined with the arthroscopic procedure. Kelly advised against it even in the presence of radiocapitellar arthritis [47], whereas Table 3 Arthroscopic procedures Number of elbows 11 25 42 Primary OA% 100 100

McLaughlin et al. felt this was an important aspect of the procedure. They reported the results of arthroscopic radial head excision with or without ulnohumeral arthroplasty in 36 patients with elbow arthritis (10 primary, 26 secondary). Twenty-eight patients had an ulnohumeral arthroplasty and radial head excision and the rest had only a radial head excision. They noted better outcome scores and arc of motion in those who had radial head excision alone (62 ) compared to patients who had a combined procedure (46 ) [44]. Complications after elbow arthroscopy are more common than other joint arthroscopies as a result of the close proximity of the neurovascular structures. The most common complication is transient nerve palsy, which occurs in up to 14% of reported series [4248]. Various techniques have been suggested to reduce neurological complications after elbow arthroscopy [42]. Other complications include deep infection (0.8%) in patients who had steroid injections postoperatively [47] and myositis ossicans [48,49]. Ulnar nerve symptoms. Most authors recommend simple decompression of the ulnar nerve, although anterior transposition is advisable in patients with a xed exion deformity of >60, and when there is a space occupying lesion such as a ganglion in the cubtal tunnel [22]. Cubital tunnel reconstruction by excision of the medial osteophytes and deepening the cubital tunnel has been advocated and reported to produce encouraging results [50]. Arthroplasty. Total elbow arthroplasty has been successfully used to treat low demand patients with inammatory arthritis, although is not routinely recommended for primary OA. There is a paucity of literature regarding prosthetic replacement for this condition. One report of linked prosthesis used in ve patients (mean age 68 months), with a minimum assessment of 3 months (range 37 months to 125 months) reported complications in four patients. These included subluxation, fracture of a humeral component with particulate synovitis, heterotopic ossication, recurrent osteophyte formation, and transient ulnar neuropathy [51]. Another series using unlinked SouterStrathclyde total elbow arthroplasties in nine elbows reported asymptomatic radiological loosening in three humeral and two ulnar components. One patient required revision for loosening and failure at a mean follow-up of 68 months (range 15 months to 117 months) [52]. Other procedures. Other procedures, to reduce elbow pain have been described, although these have not been widely adopted.

Reference

Year

Mean Follow-up Improvement Satisfaction MEPS (goodage (months) in ROM (subjective) excellent) 36 51 52.8 26 67 40.6 73 21 35 100% 90% 78.6% 100% 81%

Complication rate nil 4.7% (one hetrotopic)

Krishnan et al. [47] 2007 Kelly et al. [48] 2007 Adams et al. [49] 2008

OA, osteoarthritis; MEPS, Mayo Elbow Performance Score; ROM, range of motion.
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Bateman described denervation of the elbow in a small group of patients with elbow pain and reported improvement in pain in most patients [53]. Distraction interposition arthroplasty has also been used for young patients with post-traumatic elbow OA, although there are no published data available on this technique in primary OA [26]. References
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