Osteoarthritis & Stiffness

Elbow OA




Relatively rare

Average age 50

Men 4:1 Women

Usually dominant arm





- rare

- 2% of all cases

- associated with heavy manual labour



- trauma - intra-articular distal humerus fractures

- capitella OCD

- synovial chondromatosis

- repetitive athletic overuse




Begins radiocapitellar joint and progresses to ulnohumeral joint


Forces across joint about 1/2 body weight

- increased in strenuous work

- small cross sectional area

- increases contact stresses






End range pain

- minimal in mid range

- pain when olecranon and coronoid osteophytes impinge


Progress to pain throughout entire range in end stage of disease


Functional range

- 100 degrees flexion extension arc (30 - 130)

- 100 degrees forearm rotation (50 degrees supination and 50 degrees pronation)




Early stage

- preserved radiocapitellar and ulnohumeral joints

- osteophytes of the olecranon and coronoid


Elbow OA LateralElbow OA AP

Lateral xray demonstrating olecranon and coranoid osteophytes




Define antomy pre operation

Identification loose bodies


Elbow Arthritis CTElbow OA sagittal CT

Osteophyte of the olecranon likely impinging in extension


Elbow Loose Bodies CTElbow Loose Bodies CT 2

CT demonstrating loose bodies in the ulnohumeral joint


3D CT elbow OA 13D elbow CT OA 2

Multiple loose bodies in anterior and posterior elbow joint




Useful in detecting early chondral damage


MRI Radiocapitellar OAMRI Ulna Trochlea OA

MRI chondral damage radiocapitella joint     Chondral thinning ulnohumeral joint


MRI elbow OA

Chondral changes in the radiocapitellar and ulnohumeral joint




Capitellar Chondral InjuryRadial Head Chondral DamageUlna Chondral Damage

Chondral damage capitellum                          Chondral damage radial head                           Chondral damage ulnohumeral joint       




Inflammatory arthritis / Rheumatoid arthritis

- minimal osteophytes

- severely arthritic joint spaces

- have pain throughout range of motion


Elbow RA 1Elbow RA 2




Non operative







Limited evidence




Soft spot

- lateral approach

- triangle of lateral epicondyle / lateral olecranon / radial head


Kim et al J Clin Ultrasound 2013

- 40/40 injections intra-articular with ultrasound guidance

- 31/40 injections intra-articular with palpation guidance




Van Brackel et al Arthroscopy 2006

- 18 patients treated with 3 injections of hyaluronic acid

- some pain relief at 3 months, none at 6 months






Open debridement

Outerbridge-Kashiwagi (OK) procedure

Arthroscopic debridement

Interposition arthroplasty

Total elbow arthroplasty


Open Debridement




Remove coracoid and olecranon osteophytes

Capsular releases




Universal posterior approach


Lateral interval

- distal humeral: elevating BR and ECRL

- distal: between ECRB and EDC


Medial interval

- find and protect ulna nerve

- proximal: between triceps and brachialis

- distal: detach pronator teres


Technique Morrey


A.  Muscle releases

- brachialis released from humerus

- triceps released from humerus

B.  Capsulotomy / capsulectomy

- anteriorly elevate brachialis off capsule

C.  Excision of HO

D.  Removal of osteophytes

- coronoid / olecranon 

E.  Debridement of osteochondral flaps / loose bodies

F.  +/- Release of collateral ligaments

- preserve anterior band of MCL 

- ligament reconstruction & hinged elbow fixator if becomes unstable

G.  +/- Radial head debridement / excision


Outerbridge-Kashiwagi (OK) procedure




Posterior approach

- drill hole in distal humerus

- allows access to coranoid process for debridement


Elbow OK Procedure LateralElbow OK Procedure AP




Vumedi Outerbridge Kashiwagi (OK) procedure surgical technique


Posterior approach and triceps split

- excision of posterior capsule

- excision of tip of olecranon


Access to anterior compartment via olecranon fossa

- 1 cm diameter hole

- debridement of coranoid +/- radial head

- removal of loose bodies




Tat et al JSES 2022

- 178 OK procedures

- survivorship with total elbow arthroplasty as end point

- 100.0% at 1 year

- 98.8% at 5 years

- 98.0% at 10 years


Arthroscopic Debridement


Relative Contra-indications

- previous ulna nerve transposition

- severe soft tissue contractures

- bridging HO




Elbow osteoarthritis arthroscopic debridement surgical technique PDF


Vumedi arthroscopic debridement elbow arthroscopy


Anterior joint

- remove loose bodies

- resect coronoid osteophytes

- anterior capsular release to improve extension

- +/- radial head resection


Posterior joint

- remove loose bodies

- resect olecranon osteophytes




White et al Arthroscopy 2021

- systematic review of open versus arthroscopic debridement elbow OA

- no difference in ROM improvement / outcome measures / complications


Sochacki et al Arthroscopy 2017

- systematic review of arthroscopic debridement for elbow OA

- 9 articles and 213 elbows

- evidence of improved ROM and outcome scores with low complication


Carlier et al Orthop Traumatol Surg Res 2019

- prospective study of 87 patients

- significant improvements in pain, ROM and strength

- radial head resection did not improve outcomes




Post elbow fracture malunion / posterior impingement / FFD 40o


Elbow Malunion LateralElbow Malunion MRI


Elbow Malunion ImpingementElbow Malunion Impingement

Posterior elbow arthroscopy, with arrows pointing to olecronon tip on the right in the flexed and extended position


Elbow Malunion Partial DebridementElbow Malunion Post Debridement

Post debridement of the tip of the olecranon, in the flexed and extended elbow position


Elbow Malunion PreopElbow Malunion Post Op

Elbow extension pre and post arthroscopic debridement


Interpositional arthroplasty




Vumedi elbow interpositional arthroplasty video


Elbow interposition arthroplasty surgical technique PDF


Strip of fascia lata / achilles tendon allograft

- graft passed around end of humerus to cloth front and back


+/- hinged external fixation with distraction




Lanzerath et al Int Orthop 2022

- systematic review of 5 studies and 67 patients

- 21% revision rate


Total elbow arthroplasty (TEA)



- > 65

- sedentary




TEA uncommonly required for primary OA

? reduced long term survival compared to RA


Viveen et al Acta Orthop 2019

- 1220 TEA from Australian Joint Registry

- percentage revision was 10%, 15%, and 19% at 3, 6, and 9 years

- revision rate for OA > trauma and RA


Schoch et al JSES 2017

- 20 TEA for primary elbow OA with mean 9 years follow up

- 3 mechanical failures

- no improvement in extension