“Osteoarthritis” (AKA osteoarthrosis) is a condition in which the joint surface (cartilage) is wearing out and because the human body is not able to repair damaged cartilage there is no cure. It is far more common in other joints of the body, especially the lower limb or “weight bearing joints”.

Unlike other joints in the body, artificial elbow joints (total elbow arthroplasty, TEA) are not particularly long lasting, and should only be performed in older, lower-demand individuals. Although they relieve pain, and may improve movement, they will loosen and require revision if placed under even moderate physical demands. Revision procedures are even more difficult due to the progressive loss of bone to work with.

Hence TEA is an unsuitable choice for young active patients with early elbow OA. There are a number of non-surgical options as well as some non-arthroplasty surgical options.

CAUSE OF OSTEOARTHROSIS IN YOUNG PATIENTS

The most common cause is trauma, and usually an intra-articular fracture with resultant residual joint incongruity (a fracture that has permanently damaged the joint surface). Hence, most patients are young males.

Congenital or primary OA of the elbow is relatively rare, and only responsible for 1-2 % of cases. One of the parents of the patient usually has a similar problem.

SYMPTOMS

The feature of elbow OA which bothers patients most is the loss of movement, rather than pain (which is the opposite in other joints), and in particular the loss of extension (loss of ability to straighten the elbow). This is especially a problem with athletes and participation in many sports activities.

TREATMENT OPTIONS

NON-OPERATIVE TREATMENT

This consists of analgesia as required, correct choice of physical activity and technique adjustment if appropriate, NSAIDs, physiotherapy and physical therapy.

OPERATIVE TREATMENT

There is no cure for OA of the elbow, or any joint, but surgical procedures may help to improve function and reduce symptoms. However, the patient should realise they these are often only temporary measures, and the OA will nearly always progress.

This is especially problematic for the competitive athlete, and the goal may have to be to restore function for as long possible, but not indefinitely.

The non-arthroplasty techniques relevant to the physically active patient and/or athlete, are various forms of surgical debridement, removal of loose bodies and excision of osteophytes (bone projections often blocking movement).

SURGICAL JOINT DEBRIDEMENT

This is a relatively limited surgical procedure and may be appropriate for the carefully selected patient. Obviously results are better when the OA is limited to only part of the joint (often post-traumatic OA) rather than the whole joint. Primary OA tends to produce large osteophytes on the coronoid process and olecranon process, that gradually reduce flexion and extension respectively. Removal of these osteophytes may restore motion and reduce pain.

SURGICAL TECHNIQUE

In the first instance, and with relatively early AO, it may be possible to perform the debridement arthroscopically (“key hole surgery”). However if there are large loose bodies within the joint, and/or the disease more advanced an “open” procedure may be required. This improves the access to the joint, and the ability to excise the osteophytes, and perform capsular releases, while protecting important nerves and vessels. Most patients will receive an increase in ROM of 20-30 dg following this procedure.

The procedure is performed in an operating theatre, with the patient under a general anesthetic. The patient is usually lying on their side, with the arm to be operated on, lying over a bolster.

The incision used is often much larger than required, and this is because it is very likely that the patient will require bigger surgery in the future, and this can be complicated by skin breakdown if there are multiple scars all over the elbow joint.

Through this skin incision, the elbow joint can be opened to expose all relevant areas of the elbow joint (which has several compartments). The loose bodies and osteophytes are then excised.

The wound will be closed in layers with sutures in the skin (usually dissolvable) and the patient will wake up in recovery with the arm in heavy bandage and supported by a sling.

POST-OPERATIVE GUIDELINES FOLLOWING ELBOW DEBRIDEMENT (ARTHROSCOPIC OR OPEN)

Immediately post-operation

• You will wake up in the recovery ward with a nurse looking after you. Your arm will be in a sling and there will be dressings on your elbow. The wounds will be closed with stitches.
• You will be kept in the recovery ward until you have recovered from the anaesthetic, and have managed to have something to eat and drink.
• Your surgeon will review you before discharge to explain to you what was found during surgery and the details of the operation performed, as well as the expected outcome

Discharge to first post-operative review

• You will be asked to phone your surgeon’s rooms to make an appointment for your first post-operative review, usually 7-14 days following surgery.
• Between discharge and first review, you will be instructed to perform some simple exercises, such as bending and straightening the elbow, and rotating the forearm in both directions. It is essential that you start to perform these exercises as soon as possible following surgery to maintain the improved range of motion.
• The shoulder, forearm, wrist, hand and fingers should also be moved as often as you like.
• When not performing your exercises, keep the arm in the sling for pain relief only. Most patients will be able to do without the sling for most of the day, when they are 7 days post surgery. It can be taken of at night, unless it is more comfortable in the sling.
• Take the medication as prescribed by your anaesthetist for pain.
• Leave the dressings intact and keep the wounds dry until your first review.

First post-operative review (7-14 days post surgery)

• At this review your surgeon will check the wound and remove the stitches.
• He will go over the operative findings and procedure performed.
• He will also refer you for physiotherapy to supervise your rehabilitation if required
• A second review appointment will be made for 6 weeks post surgery if required.

Second post-operative review

• At this review the surgeon will assess your progress and re-examine the elbow.
• He will also discuss and residual problems that you are having as well as measures to remedy them such as adjustments to the physical therapy and exercises performed.

Return to specific activities

• Driving – this is usually possible within 7 days of surGery
• Return to work – for light clerical or supervisory duties, this may be possible within one week of surgery, while heavy physical demands will require up to 6 weeks (depends upon the severity of the problem and the specific surgery performed)
• Cross training – the patient will often be able to sit on a stationary bike and/or run within a few days of surgery, and certainly soon after the sutures have been removed
• Water-based training – is usually possible soon after the wounds have completely healed
• Weight training – again this depends upon the specific surgery required. The longest delay following surgery is usually 6 weeks, while many patients are bale to make a graded return to resistance training and the weights proper starting within 4 weeks of surgery
• Return to full contact sport and/or competition – is determined more by restoration of full range of motion and strength, and can vary from 3 weeks to 3 months depending upon the sport and the magnitude of surgery performed.