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Arthritis & Degeneration

Elbow arthritis (OA, RA, PTA): diagnosis, non-operative management, and timing/options for elbow replacement or salvage procedures.

Overview

Joint preservation procedures offer satisfactory short-term outcomes for glenohumeral and elbow arthritis, though they have yet to demonstrate the ability to halt arthritic progression [2]. For primary osteoarthritis of the elbow, joint-sparing surgical procedures are preferred [25]. The extent of degenerative joint disease of the radiocapitellar joint negatively affects postoperative outcomes, while a developed radiographic classification system for primary osteoarthritis appears valid in predicting these results [3]. The long-term durability of arthroscopic ulnohumeral arthroplasty in patients under fifty years of age, regarding preservation of ROM and radiographic progression, remains unknown [1].

Reverse arthroplasty achieves highly favorable outcomes for glenohumeral osteoarthritis with an intact rotator cuff [14]. However, longer follow-up is needed to determine the ultimate value of reverse shoulder arthroplasty in this setting [16]. The AAOS developed Appropriate Use Criteria to determine the appropriateness of various treatments for shoulder osteoarthritis with intact rotator cuff and severe glenoid retroversion [43]. Guidelines provide 18 recommendations for nonoperative and operative treatment of osteoarthritis of the hip to assist practitioners in decision-making [12].

Joint replacement procedures relieve pain and improve function more than other current operative treatments but are limited by the inability of synthetic materials to duplicate the properties of articular cartilage [24]. Procedures that restore rather than replace the joint may offer advantages for young patients or those with less advanced disease [24]. Total elbow arthroplasty is indicated primarily for patients with rheumatoid arthritis who are low demand and have Larsen stage 3 to 5 lesions [25]. Radial head arthroplasty results in satisfactory clinical outcomes and modest complication and revision rates at long-term follow-up (minimum 8 years), despite high levels of radiologic degenerative changes over the same period [8].

A distinction between symptomatic and asymptomatic radiographic acromioclavicular osteoarthritis is unnecessary, as all patients were equally satisfied with the outcome of preoperative acromioclavicular injection [15]. Proximal-row carpectomy should be considered after conservative measures fail for diseases of the proximal row, as mild degenerative arthritis is not a contraindication and progressive degenerative arthritis of the radial capitate articulation did not occur [18].

Anatomy & Pathophysiology

Surgical treatment for elbow arthritis is based on disease etiology, severity of degeneration, and patient age [21]. The purpose of reviewing elbow arthritis includes discussing pertinent soft tissue and osseous anatomy, etiologies, diagnosis, evaluation, and treatment options [60].

Osseous Anatomy & Degeneration

Osteophytic change occurs predominantly in the ulnohumeral compartment of the elbow [61]. Joint space narrowing more frequently affects the radiocapitellar articulation [61]. Three-dimensional computational models identified unique regions of bony impingement in patients with osteoarthritis of the elbow, such as between the radial head and a posterior capitellar osteophyte in extension [68].

Radial Head Mechanics

Contact analysis of the native radiocapitellar joint compared with axisymmetric and nonaxisymmetric radial head hemiarthroplasty showed that a nonaxisymmetric radial head can provide improved contact mechanics at certain forearm rotations and flexions [37]. There are orientations where contact area is reduced and stress is increased with nonaxisymmetric radial heads [37].

Surgical Considerations

Interposition arthroplasty can improve elbow motion and function but at the expense of elbow stability despite hinged external fixation [55]. Elbow arthroscopy remains a technically difficult procedure with the potential for neurologic complications [69].

Classification

Primary Elbow Osteoarthritis: A developed classification system appears valid in predicting postoperative outcome [3]. The extent of degenerative joint disease of the radiocapitellar joint negatively affects postoperative outcome [3]. An extended Samilson-Prieto classification for humeral head pathomorphology in primary osteoarthritis proposes type A (spherical) and type B (aspherical) morphologies with grade I-IV osteophytes [56]. The long-term durability of arthroscopic ulnohumeral arthroplasty regarding preservation of ROM and radiographic progression of arthritis in patients under fifty years of age remains unknown [1].

Glenohumeral Osteoarthritis: The Walch classification is valid, simple, and continues to be a reliable and valuable method for assessing the glenoid in osteoarthritic glenoids [38]. It provides an anatomic descriptive characterization of primary glenohumeral osteoarthritis to guide surgical management and communication, though interobserver reliability varies from fair to moderate across different studies [59]. The Walch classification system is not as reliable as initially suggested, but it is an acceptable classification system that should continue to be used until a more reliable system is developed [41].

Rheumatoid Arthritis: The revised 1958 criteria for rheumatoid arthritis are intended to aid in obtaining more uniformity in the classification of patients with rheumatoid arthritis [39]. The Larsen and Sharp systems both show substantial intraobserver reliability and good interobserver agreement for the radiographic classification of rheumatoid arthritis affecting the elbow [47].

Other Considerations: No OA-related biomarker can currently be considered a surrogate marker of clinical and imaging features for the diagnosis or prognosis of osteoarthritis [9]. An integrative bioinformatics analysis identified potential diagnostic biomarkers for osteoarthritis, with a developed nomogram showing promise for accurate OA diagnosis [13]. Predictive MRI signs have been identified in patients with symptomatic acromioclavicular osteoarthritis [10]. The sequence of events in bilateral primary cystic arthrosis of the acetabulum supports the theory that cystic arthrosis is a primary phenomenon that may precede and hasten the onset of osteoarthritis [17]. Posterolateral stabilization of the elbow by autologous ligament reconstruction prevents the development of osteoarthritis or the worsening of pre-existing osteoarthritis in the absence of associated lesions [6]. Recognition and classification of sternoclavicular joint injuries are critical to proper management to minimize long-term sequelae [57]. An AI network demonstrates robust capability to identify cuff tear arthropathy on plain radiographs, with exceptional performance in later disease stages [26].

Clinical Presentation

Surgical intervention for elbow arthritis is determined by disease etiology, severity of degeneration, and patient age [21]. In patients under fifty, arthroscopic ulnohumeral arthroplasty for degenerative arthritis has unknown long-term durability regarding preservation of ROM and radiographic progression of arthritis [1]. Early results of glenohumeral joint preservation procedures indicate satisfactory short-term outcomes, though these procedures have yet to show they can halt arthritic progression [2]. Noncemented total elbow arthroplasty has reliable clinical and radiographic outcomes at long-term follow-up in the younger population with inflammatory arthritis [4].

Radiographic severity of glenohumeral osteoarthritis does not correlate with patient-reported pain and function, and symptoms should remain the primary determinants of surgical decision-making [22]. A review discusses the various causes leading to early glenohumeral arthritis in young patients, their clinical presentation, and the challenges associated with treatment options [33]. Specific exfoliative cytological patterns can be readily recognized in fluids aspirated from joints in a variety of arthritides, supporting the technique as a valuable diagnostic aid [34].

There is a symptomatic detriment associated with hyaluronic acid (HA) in osteoarthritic joints with exposed bony areas [36]. No OA-related biomarkers can currently be considered a surrogate marker of clinical and imaging features for the diagnosis or prognosis of the disease [9]. Patients with edema on MRI are more likely to present pain than patients without edema in acromioclavicular joint osteoarthritis [23]. Predictive MRI signs have been identified in patients with symptomatic AC osteoarthritis [10]. Asymptomatic acromioclavicular osteoarthritis diagnosed by MRI remained asymptomatic in 90% of patients over a 7-year course [7].

Rapidly destructive arthrosis of the shoulder joints presents with unique radiographic features, MRI findings, and a specific clinical course characterized by rapid humeral head collapse [11]. Posterolateral stabilization of the elbow by autologous ligament reconstruction prevents the development of osteoarthritis or the worsening of pre-existing osteoarthritis in the absence of associated lesions [6].

Palindromic rheumatism requires ruling out other arthritic disorders and observing a protracted, non-destructive course over time for final diagnosis [5]. The diagnosis of the articular manifestations of periodic disease (Familial Mediterranean Fever) is clinical, based on the association of monoarticular arthritis with recurrent fever and abdominal pain, as there are no specific laboratory aids [35]. While joint involvement in familial Mediterranean fever is typically transient, permanent joint damage can occur, particularly in older children at onset [20].

Investigations

Plain radiography: Radiographic severity of glenohumeral osteoarthritis does not correlate with patient-reported pain and function [22]. Increased age is the main determinant of radiological changes in shoulder OA and pain [81]. A new radiographic classification system for primary osteoarthritis of the elbow appears valid in predicting postoperative outcome [3]. An automated classification network demonstrates robust capability to identify cuff tear arthropathy on plain radiographs, with exceptional performance in later disease stages [26].

MRI: MRI should be performed if healing does not occur by a reasonable time despite successful bony healing to assess potential cartilage damage in osteochondritis dissecans of the capitellum [46]. Predictive MRI signs have been identified in patients with symptomatic AC osteoarthritis [10]. Patients with edema on MRI are more likely to present pain than patients without edema in acromioclavicular joint osteoarthritis [23]. Types A and B mediopatellar plicae were commonly observed on MRI in a cohort of subjects with knee pain [85]. Rapidly destructive arthrosis of the shoulder joints presents with unique radiographic features and specific MRI findings characterized by rapid humeral head collapse [11].

Laboratory: No OA-related biomarker is currently considered a surrogate marker of clinical and imaging features for the diagnosis or prognosis of the disease [9]. Integrative bioinformatics analysis identifies potential diagnostic biomarkers for osteoarthritis, with a developed nomogram showing promise for accurate OA diagnosis [13].

Other Considerations: Asymptomatic acromioclavicular osteoarthritis (AC-OA) diagnosed by MRI remained asymptomatic in 90% of patients over a seven-year course [7]. A preoperative acromioclavicular injection suggests that a distinction between symptomatic and asymptomatic radiographic AC OA is unnecessary, as all patients were equally satisfied with the outcome [15]. Subchondral bone edema on histologic examination is more frequent in patients with pain in acromioclavicular joint osteoarthritis [23]. Symptoms should remain the primary determinants of surgical decision-making for glenohumeral osteoarthritis [22]. Final diagnosis of palindromic rheumatism requires ruling out other arthritic disorders and observing a protracted, non-destructive course over time [5]. A population-based study assessed the prevalence of ultrasound features of OA in the hand, knee, and hip at age 63 years [83].

Treatment

Nonoperative Management

Nonoperative treatment is the standard initial approach for primary and posttraumatic elbow arthritis, with surgical intervention reserved for cases refractory to conservative management [70]. For shoulder osteoarthritis, nonoperative modalities are recommended prior to surgical options, particularly in patients with moderate-to-mild disease [72]. In the hip, management guidelines provide 18 recommendations for both nonoperative and operative treatment to assist practitioners in decision-making [12]. Nonoperative strategies are also beneficial for most painful acromioclavicular joint conditions, although patients with osteolysis may need to modify activities [73]. Physical therapy plays a comprehensive role in the conservative, nonoperative, and postoperative management of osteochondritis dissecans [77]. For neuropathic shoulder arthropathy, nonoperative treatment emphasizes function maintenance over immobilization, as arthrodesis is contraindicated and synovectomy is ineffective [48]. In rheumatoid arthritis, intra-articular TNFi therapy demonstrates efficacy equal to intra-articular steroids, though optimal dosing and frequency remain undefined [51]. Despite improved synovitis control in rheumatoid arthritis, disability measured by HAQ has not shown comparable reductions [45]. Future research is required to develop molecules with improved efficacy and safety profiles for rheumatoid arthritis until a cure is identified [40].

Operative

Indications: Joint-sparing surgical procedures are preferred for elbow osteoarthritis [25]. Total elbow arthroplasty is primarily indicated for low-demand patients with rheumatoid arthritis and Larsen stage 3 to 5 lesions [25]. In younger populations with inflammatory arthritis, noncemented total elbow arthroplasty offers reliable clinical and radiographic long-term outcomes [4]. Synovectomy may relieve symptoms in rheumatoid elbow patients unresponsive to nonsurgical management, while arthroplasty is a reasonable alternative for advanced disease [66]. Operative debridement is offered for elbow osteoarthritis patients with pain at terminal extension or flexion who are dissatisfied with nonoperative treatments [75]. Glenohumeral osteoarthritis with an intact rotator cuff is treated with reverse shoulder arthroplasty [14]. Proximal-row carpectomy is considered for proximal row diseases after conservative measures fail, as mild degenerative arthritis is not a contraindication [18]. Surgical excision of mediopatellar plica associated with cartilage degeneration is an effective treatment modality [54]. Treatment options for hallux rigidus and first metatarsophalangeal joint osteoarthrosis range from non-operative measures to cheilectomy, arthroplasty, and arthrodesis, selected based on disease stage and patient factors [76].

Surgical Approach / Technique: Arthroscopic ulnohumeral arthroplasty is performed for degenerative elbow arthritis in patients under fifty years of age [1]. Posterolateral stabilization via autologous ligament reconstruction prevents the development or worsening of osteoarthritis in the absence of associated lesions [6]. Joint replacement procedures relieve pain and improve function more than other current operative treatments for osteoarthrosis [24]. Procedures that restore rather than replace the joint may offer advantages for young patients or those with less advanced disease [24]. Early results of glenohumeral joint preservation procedures for young, active patients with osteoarthritis indicate satisfactory short-term outcomes [2].

Implant Selection: Long-term outcomes of radial head arthroplasty for radial head fractures show satisfactory clinical results and modest complication and revision rates, despite high levels of radiologic degenerative changes over the same period [8]. Joint replacement procedures are limited by the inability of synthetic materials to duplicate the properties of articular cartilage [24].

Alignment / Balancing Strategy: Management of glenohumeral osteoarthritis remains controversial, and scientific evidence on this topic can be significantly improved [79].

Adjuncts: Existing literature demonstrates anti-inflammatory properties of orthobiologics for osteoarthritis management, but no treatment has clearly demonstrated significant joint preservation properties, including the ability to reverse progression of osteoarthritis [42].

Other Considerations: Patients undergoing operative debridement for elbow osteoarthritis should expect modest and unpredictable improvement in range of motion and no change in the disease process [75]. Arthroscopic ulnohumeral arthroplasty in patients under fifty has unknown long-term durability regarding preservation of ROM and radiographic progression of arthritis [1]. Despite appropriate and aggressive treatment, the prognosis for osteochondritis dissecans of the capitellum remains guarded, with long-term results demonstrating continued elbow symptoms and degenerative joint disease in approximately 50% of patients [44]. Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop [27].

Complications

Long-term Arthritic Progression: The long-term durability of arthroscopic ulnohumeral arthroplasty regarding preservation of ROM and radiographic progression of arthritis remains unknown [1]. Joint preservation procedures for young, active patients with osteoarthritis have yet to show they can halt arthritic progression [2]. The extent of degenerative joint disease of the radiocapitellar joint has a negative effect on postoperative outcome [3]. Osteoarthritis consists of a retrogressive sequence of changes in cells and matrix accompanied by repair and remodeling reactions that vary in rate and may stabilize or decrease spontaneously [31]. Cystic arthrosis is a primary phenomenon that may precede and hasten the onset of osteoarthritis [17]. Osteoarthritis will most likely develop in patients with established scaphoid non-union [27].

Implant-Specific Complications and Outcomes: Noncemented total elbow arthroplasty (TEA) in younger patients with inflammatory arthritis has reliable outcomes clinically and radiographically at long-term follow-up [4]. A high rate of complications and revisions was observed with follow-up for semiconstrained total elbow arthroplasty performed for arthritis in patients under 55 years old [49]. Major primary complications and a high incidence of radiographic signs of degenerative changes occurred after 8.8 years following bipolar radial head arthroplasty [64]. Radial head arthroplasty (RHA) results in satisfactory clinical outcomes and modest complication and revision rates at long-term follow-up, despite high levels of radiologic degenerative changes [8]. Reverse shoulder arthroplasty can achieve highly favorable outcomes for glenohumeral osteoarthritis with an intact rotator cuff [14]. Longer follow-up is needed to determine the ultimate value of reverse shoulder arthroplasty (RSA) in the setting of osteoarthritis [16].

Disease-Specific and Natural History Complications: Palindromic rheumatism follows a protracted, non-destructive course over time [5]. Permanent joint damage can occur in familial Mediterranean fever, particularly in older children at onset [20]. The progressive nature of cervical rheumatoid disease resulted in the recurrence of long-tract symptoms in three patients due to further subaxial subluxation distal to the original fusion site [28]. Rheumatologists welcome the aggressive orthopaedic approach to preventing cartilage destruction in rheumatoid arthritis [80]. Osteoarthritis is not induced and there is no danger of recurrence in the medium term following surgical treatment of chondromatosis of the elbow [19]. The true cause, natural history, and optimal treatment of osteochondritis dissecans of the capitellum remain unknown [30].

Other Considerations: Asymptomatic acromioclavicular osteoarthritis (AC-OA) diagnosed by MRI remained asymptomatic in 90% of cases over 7 years [7]. Double semitendinosus anterior cruciate ligament reconstruction stabilises the evolution of degenerative lesions as shown by standing X-ray [84].

Recovery

Light activity (weeks): Evidence does not provide specific week ranges for light activity or desk work return.

Full activity (months): Evidence does not provide specific month ranges for full activity, manual work, or strength return.

Complete recovery / outcome plateau (months): Evidence does not provide specific month ranges for final functional outcome stabilization.

Rehabilitation protocol: Following arthroscopic arthrolysis for traumatic and degenerative elbow contracture, range of motion gains achieved during surgery may not be fully recovered postoperatively; after an initial early deterioration, the gain in range of motion slowly recovers over a period of 6 months [86].

Functional milestones: Early results of glenohumeral joint preservation procedures indicate satisfactory short-term outcomes, though these procedures have yet to show they can halt arthritic progression [2]. Short-term functional outcomes after total elbow arthroplasty in patients with posttraumatic arthritis or deformities were good according to mean postoperative measurements [29]. Mid-term results with Coonrad-Morrey prosthesis for total elbow replacement in rheumatoid arthritis show satisfactory functional results with no evidence of loosening or instability [78]. Radial head arthroplasty results in satisfactory clinical outcomes and modest complication and revision rates at long-term follow-up (minimum 8 years), despite high levels of radiologic degenerative changes over the same period [8]. Noncemented total elbow arthroplasty has reliable clinical and radiographic outcomes at long-term follow-up in the younger population with inflammatory arthritis [4].

Other Considerations: The long-term durability of arthroscopic ulnohumeral arthroplasty regarding preservation of range of motion and radiographic progression of arthritis remains unknown [1]. Longer follow-up is needed to determine the ultimate value of reverse shoulder arthroplasty in the setting of osteoarthritis [16]. Longer follow-up is required to see whether pyrocarbon interposition shoulder arthroplasty survival will be superior to that of hemiarthroplasty [74]. The extent of degenerative joint disease of the radiocapitellar joint has a negative effect on postoperative outcome in primary osteoarthritis of the elbow [3]. A developed classification system for primary osteoarthritis of the elbow appears valid in predicting postoperative outcome [3]. Osteoarthritis consists of a retrogressive sequence of changes in cells and matrix accompanied by repair and remodeling reactions that vary in rate and may stabilize or decrease spontaneously [31]. Asymptomatic acromioclavicular osteoarthritis diagnosed by MRI remained asymptomatic in 90% of cases over a 7-year course [7]. Rapidly destructive arthrosis of the shoulder joints is characterized by a specific clinical course involving rapid humeral head collapse [11]. The sequence of events in bilateral primary cystic arthrosis of the acetabulum supports the theory that cystic arthrosis is a primary phenomenon that may precede and hasten the onset of osteoarthritis [17]. Osteoarthritis is not induced and there is no danger of recurrence in the medium term following arthroscopic and open options for surgical treatment of chondromatosis of the elbow [19]. The true cause, natural history, and optimal treatment of osteochondritis dissecans of the capitellum remain unknown [30]. The progressive nature of cervical rheumatoid disease resulted in the recurrence of long-tract symptoms in three patients due to further subaxial subluxation distal to the original fusion site [28]. The final diagnosis of palindromic rheumatism requires ruling out other arthritic disorders and observing a protracted, non-destructive course over time [5].

Key Evidence

  • [L4] The long-term durability of this procedure with regard to preservation of ROM and radiographic progression of arthritis remains unknown. (10.1016/j.jse.2006.09.001)
  • [L4] Early results indicate satisfactory short-term outcomes, though these procedures have yet to show they can halt arthritic progression. (10.1155/2012/160923)
  • [L4] The extent of degenerative joint disease of the radiocapitellar joint had a negative effect on postoperative outcome, and the developed classification system appears valid in predicting postoperative outcome. (10.1016/j.jse.2007.03.014)
  • [L4] In the younger population with inflammatory arthritis, noncemented TEA has reliable outcomes clinically and radiographically at long-term follow-up. (10.1016/j.jse.2014.02.026)
  • [L4] In the absence of associated lesions, it prevents the development of osteoarthritis or the worsening of pre-existing osteoarthritis. (10.1016/j.jse.2023.01.011)
  • [L2] Asymptomatic AC-OA remained asymptomatic in 90% over 7 years. (10.1016/j.jse.2019.04.004)
  • [L4] Our systematic review established that RHA results in satisfactory clinical outcomes and modest complication and revision rates at long-term follow-up, despite high levels of radiologic degenerative changes over the same period. (10.1016/j.jse.2021.03.142)
  • [L5] Although many OA-related biomarkers are currently available, none can be considered as a surrogate marker of clinical and imaging features for the diagnosis or prognosis of the disease at this time. (10.1186/1471-2474-16-s1-s2)
  • [L4] We identified predictive MRI signs in patients with symptomatic AC osteoarthritis. (10.1016/j.jse.2018.01.001)
  • [L4] Rapidly destructive arthrosis presents with unique radiographic features, MRI findings, and a specific clinical course characterized by rapid humeral head collapse. (10.1016/j.jse.2014.10.020)
  • [L1] The guideline provides 18 recommendations for nonoperative and operative treatment based on relevant literature to assist practitioners in making decisions regarding the most appropriate treatment for osteoarthritis of the hip. (10.5435/jaaos-d-19-00416)
  • [L5] The study provides insights into OA pathogenesis and identifies potential diagnostic biomarkers, with a developed nomogram showing promise for accurate OA diagnosis. (10.1186/s12891-024-08124-3)
  • [L4] The findings suggest that reverse arthroplasty can achieve highly favorable outcomes for this indication. (10.1016/j.jse.2021.06.010)
  • [L4] The outcomes of this study seem to suggest that a distinction between symptomatic and asymptomatic radiographic AC OA is unnecessary, as all patients were equally satisfied with the outcome. (10.5397/cise.2023.00073)
  • [L3] Longer follow-up is needed to determine the ultimate value of RSA in the setting of osteoarthritis. (10.2106/jbjs.21.00982)
  • [Case_report] The sequence of events supports the theory that cystic arthrosis is a primary phenomenon that may precede and hasten the onset of osteoarthritis. (10.2106/00004623-199605000-00019)
  • [L4] It should be considered after conservative measures fail, as mild degenerative arthritis is not a contraindication and progressive degenerative arthritis of the radial capitate articulation did not occur. (10.2106/00004623-197759040-00004)
  • [L3] Osteoarthritis is not induced and there is no danger of recurrence in the medium term. (10.1016/j.arthro.2007.12.002)
  • [L4] While joint involvement is typically transient, this report emphasizes that permanent joint damage can occur, particularly in older children at onset. (10.2106/00004623-197557020-00023)
  • [L5] Surgical treatment for elbow arthritis is based on disease etiology, severity of degeneration, and patient age. (10.1016/j.jhsa.2007.12.022)
  • [L3] Radiographic severity of glenohumeral osteoarthritis does not correlate with patient-reported pain and function, and symptoms should remain the primary determinants of surgical decision-making. (10.1177/2471549220901873)
  • [L4] Patients with edema on MRI were more likely to present pain than patients without edema, and subchondral bone edema on histologic examination was more frequent in patients with pain. (10.1016/j.jseint.2020.03.007)
  • [L5] Joint replacement procedures relieve pain and improve function more than other current operative treatments but are limited by the inability of synthetic materials to duplicate the properties of articular cartilage; procedures that restore rather than replace the joint may offer advantages for young patients or those with less advanced disease. (10.2106/00004623-199409000-00019)
  • [L4] The study demonstrates the network's robust capability to identify cuff tear arthropathy on plain radiographs, with exceptional performance in later disease stages. (10.1186/s12891-026-09603-5)
  • [L4] Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop. (10.2106/00004623-198567030-00013)
  • [L4] The progressive nature of cervical rheumatoid disease resulted in the recurrence of long-tract symptoms in three patients due to further subaxial subluxation distal to the original fusion site. (10.2106/00004623-198163080-00003)
  • [L4] Short-term functional outcomes after total elbow arthroplasty in this prospective cohort of patients with posttraumatic arthritis or deformities of the elbow were good according to mean postoperative measurements. (10.1016/j.jhsa.2013.03.051)
  • [L5] The true cause, natural history, and optimal treatment of osteochondritis dissecans of the capitellum remain unknown. (10.1177/0363546509354969)
  • [L5] Osteoarthritis is not simply the result of aging and mechanical wear from joint use, nor is primary osteoarthritis caused by inflammation; it consists of a retrogressive sequence of changes in cells and matrix accompanied by repair and remodeling reactions that vary in rate and may stabilize or decrease spontaneously. (10.2106/00004623-199704000-00022)
  • [L4] This review discusses the various causes leading to early glenohumeral arthritis in young patients, their clinical presentation, and the challenges associated with treatment options. (10.1016/j.jse.2010.11.014)
  • [L4] Specific exfoliative cytological patterns can be readily recognized in fluids aspirated from joints in a variety of arthritides, supporting the technique as a valuable diagnostic aid. (10.2106/00004623-197658030-00019)
  • [L4] The diagnosis is clinical, based on the association of monoarticular arthritis with recurrent fever and abdominal pain, as there are no specific laboratory aids. (10.2106/00004623-196547080-00016)
  • [L4] There is a symptomatic detriment associated with HA in osteoarthritic joints with exposed bony areas. (10.1016/j.arthro.2020.12.172)
  • [L5] Whereas a nonaxisymmetric radial head can provide improved contact mechanics at certain forearm rotations and flexions, there are also orientations where contact area is reduced and stress is increased. (10.1016/j.jse.2014.12.011)
  • [L4] The Walch classification is valid, simple, and continues to be a reliable and valuable method for assessing the glenoid in osteoarthritic glenoids. (10.1111/j.1758-5740.2011.00151.x)
  • [L5] The revised criteria are hoped to aid in obtaining more uniformity in the classification of patients with rheumatoid arthritis and should be reviewed in two or three years. (10.2106/00004623-195941040-00023)
  • [L5] Future research is needed to develop molecules with improved efficacy and safety profiles until RA becomes a curable pathology. (10.3390/cells10112857)
  • [L2] While the Walch classification system is not as reliable as initially suggested and improvement would be of utility, it is an acceptable classification system that should continue to be used until a more reliable system is developed. (10.1016/j.jse.2009.08.003)
  • [L5] Existing literature demonstrates anti-inflammatory properties of orthobiologics, but no treatment has clearly demonstrated significant joint preservation properties, including the ability to reverse progression of osteoarthritis. (10.1136/jisakos-2019-000377)
  • [L5] The AAOS developed Appropriate Use Criteria to determine the appropriateness of various treatments for shoulder osteoarthritis with intact rotator cuff and severe glenoid retroversion, utilizing a multidisciplinary panel to rate 240 patient scenarios across five treatment options. (10.5435/jaaos-d-23-00669)
  • [L5] Despite appropriate and aggressive treatment, the prognosis for osteochondritis dissecans of the capitellum remains guarded, with long-term results demonstrating continued elbow symptoms and degenerative joint disease in approximately 50% of patients. (10.1016/j.jse.2009.11.058)
  • [L4] However, these improvements in controlling synovitis have not resulted in comparable reductions in disability measured by HAQ. (10.1186/s12891-016-0897-y)
  • [Case_report] The authors recommend performing an MRI if healing does not occur by a reasonable time despite successful bony healing to assess potential cartilage damage. (10.1007/s00402-005-0018-0)
  • [L4] The Larsen and Sharp systems both show substantial intraobserver reliability and good interobserver agreement for the radiographic classification of rheumatoid arthritis affecting the elbow. (10.1016/j.jse.2016.07.074)
  • [L4] Neuropathic arthropathy of the shoulder is a contraindication to arthrodesis and synovectomy is not helpful; the condition should be treated nonoperatively with an emphasis on the maintenance of function rather than immobilization. (10.2106/00004623-199809000-00010)
  • [L4] However, a high rate of complications and revisions was observed with follow-up. (10.1016/j.jse.2019.08.006)
  • [L1] Intra-articular TNFi therapy appears to have equal efficacy to IA steroids, though the optimal dose and frequency of injections is yet unknown. (10.1186/s12891-021-04651-5)
  • [L3] Surgical excision of mediopatellar plica associated with cartilage degeneration appears to result in substantial clinical improvement, thus representing an effective treatment modality for this group of patients. (10.1007/s00167-010-1125-1)
  • [L4] Interposition arthroplasty can improve elbow motion and function but at the expense of elbow stability despite hinged external fixation. (10.1016/j.jse.2007.11.008)
  • [L4] The authors propose an extended Samilson-Prieto classification with type A (spherical) and type B (aspherical) and grade I-IV osteophytes. (10.1016/j.jse.2017.07.009)
  • [L1] Injuries to the SC joint are uncommon, and recognition and classification are critical to proper management to minimize long-term sequelae. (10.1177/0363546513498990)
  • [L5] The Walch classification provides an anatomic descriptive characterization of primary glenohumeral osteoarthritis to guide surgical management and communication, though interobserver reliability varies from fair to moderate across different studies. (10.1007/s11999-017-5317-6)
  • [L5] The purpose of this article is to review the pertinent soft tissue and osseous anatomy, discuss the etiologies, review the principles of diagnosis and evaluation, and finally, study the treatment options for elbow arthritis. (10.1016/j.jhsa.2022.12.014)
  • [L3] Osteophytic change occurs predominantly in the ulnohumeral compartment of the elbow, whereas joint space narrowing more frequently affects the radiocapitellar articulation. (10.1016/j.jse.2006.08.005)
  • [L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. (10.1016/j.jse.2010.05.022)
  • [L5] Synovectomy may provide relief of symptoms for patients unresponsive to nonsurgical management, while arthroplasty is a reasonable alternative for those with more advanced disease. (10.5435/00124635-200303000-00004)
  • [L4] Three-dimensional computational models identified the locations and volumes of bony impingement in patients with osteoarthritis of the elbow and highlighted unique regions of impingement, such as between the radial head and a posterior capitellar osteophyte in extension. (10.1016/j.jhsa.2013.03.035)
  • [L4] Elbow arthroscopy remains a technically difficult procedure with the potential for neurologic complications. (10.1016/j.arthro.2006.11.021)
  • [L5] Nonoperative treatment is almost always initiated although surgical treatment may be indicated in cases refractory to conservative management. (10.1155/2013/473259)
  • [L5] The article provides an overview of available treatments for shoulder osteoarthritis, noting that nonoperative modalities should be utilized before surgical options, particularly for patients with moderate-to-mild disease, while surgical treatments like arthroplasty are considered effective for severe cases. (10.1155/2013/370231)
  • [L5] Nonoperative treatment is helpful for most patients, although those with osteolysis may have to modify their activities. (10.5435/00124635-199905000-00004)
  • [L4] Longer follow-up is required to see whether PISA survival will be superior to that of hemiarthroplasty. (10.1016/j.jse.2019.05.044)
  • [L4] Operative debridement is offered for pain at terminal extension or flexion in patients not satisfied with nonoperative treatments, but patients should expect modest and unpredictable improvement in range of motion and no change in the disease process. (10.1016/j.jhsa.2011.05.001)
  • [L5] Treatment options range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis, with selection depending on disease stage and patient factors. (10.2106/00004623-199806000-00015)
  • [Paper] Physical therapy management of osteochondritis dissecans can incorporate a full spectrum of conservative, nonoperative, and postoperative care. (10.1016/j.csm.2014.01.001)
  • [L3] Our mid-term results with Coonrad-Morrey show satisfactory functional results with no evidence of loosening or instability. (10.1016/j.jse.2009.09.016)
  • [L1] Management of glenohumeral osteoarthritis remains controversial; the scientific evidence on this topic can be significantly improved. (10.5435/00124635-201006000-00010)
  • [L5] The paper concludes that understanding the pathogenesis of rheumatoid arthritis is advancing rapidly, suggesting that once the nature of the disease is known, means of cure, prevention, or control will follow, while rheumatologists welcome the aggressive orthopaedic approach to preventing cartilage destruction. (10.2106/00004623-196850030-00020)
  • [L3] This study shows that increased age is the main determinant of radiological changes in shoulder OA, as well as pain. (10.1186/s13018-022-03137-x)
  • [L1] Given these effects, CT presents a promising agent for the treatment of both diseases, although the potential seems to be greater in OA. (10.1530/eor-23-0133)
  • [L4] This is the first study to assess prevalence of ultrasound features of OA in a population-based sample. (10.1186/1471-2474-15-162)
  • [L4] The study shows that the procedure is efficient in restoring a satisfactory stability for most patients and stabilises the evolution of the degenerative lesions as shown by standing X-ray. (10.1007/s001670050076)
  • [L3] On MRI, types A and B mediopatellar plicae were commonly observed in this cohort of subjects with knee pain. (10.1186/1471-2474-14-292)
  • [L4] After early deterioration, the achieved gain slowly recovers over a period of 6 months but may not recover to the ranges achieved during arthroscopy. (10.1016/j.jse.2018.02.068)

See Also

References

[1] Arthroscopic ulnohumeral arthroplasty for degenerative arthritis of the elbow in patients under fifty years of age. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.09.001

[2] Glenohumeral Joint Preservation: A Review of Management Options for Young, Active Patients with Osteoarthritis. Advances in Orthopedics. 2012. DOI: 10.1155/2012/160923

[3] Primary osteoarthritis of the elbow: Lack of radiographic evidence for morphologic predisposition, results of operative debridement at intermediate follow-up, and basis for a new radiographic classification system. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.03.014

[4] Results of custom-fit, noncemented, semiconstrained total elbow arthroplasty for inflammatory arthritis at an average of eighteen years of follow-up. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.02.026

[5] Palindromic Rheumatism: An Unusual Cause of the Inflammatory Joint: TWO CASE REPORTS AND A REVIEW.. The Journal of Bone and Joint Surgery. American Volume. 1974.

[6] Posterolateral stabilization of the elbow by autologous ligament reconstruction to limit long-term development of osteoarthritis. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.01.011

[7] Seven-year course of asymptomatic acromioclavicular osteoarthritis diagnosed by MRI. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.04.004

[8] Long-term outcomes of radial head arthroplasty for radial head fractures—a systematic review at minimum 8-year follow-up. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.03.142

[9] Biomarkers of prognosis and efficacy of treatment in OA. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/1471-2474-16-s1-s2

[10] Predictive findings on magnetic resonance imaging in patients with symptomatic acromioclavicular osteoarthritis. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.01.001

[11] Rapidly destructive arthrosis of the shoulder joints: radiographic, magnetic resonance imaging, and histopathologic findings. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.10.020

[12] Management of Osteoarthritis of the Hip. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-19-00416

[13] Integrative bioinformatics analysis reveals novel insights into osteoarthritis pathogenesis and diagnostic biomarkers. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-08124-3

[14] Glenohumeral osteoarthritis with intact rotator cuff treated with reverse shoulder arthroplasty: a systematic review. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.06.010

[15] Diagnostic value of a preoperative acromioclavicular injection for symptomatic acromioclavicular osteoarthritis: a retrospective study of cross-sectional midterm outcomes. Clinics in Shoulder and Elbow. 2024. DOI: 10.5397/cise.2023.00073

[16] Outcomes After Anatomic and Reverse Shoulder Arthroplasty for the Treatment of Glenohumeral Osteoarthritis. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.21.00982

[17] Bilateral Primary Cystic Arthrosis of the Acetabulum. A Case Report. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199605000-00019

[18] Proximal-row carpectomy for diseases of the proximal row. The Journal of Bone & Joint Surgery. 1977. DOI: 10.2106/00004623-197759040-00004

[19] Arthroscopic and Open Options for Surgical Treatment of Chondromatosis of the Elbow. Arthroscopy. 2008. DOI: 10.1016/j.arthro.2007.12.002

[20] Articular damage in familial Mediterranean fever. Report of four cases. The Journal of Bone & Joint Surgery. 1975. DOI: 10.2106/00004623-197557020-00023

[21] Surgical Options for the Arthritic Elbow. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.12.022

[22] Severity of Glenohumeral Osteoarthritis Does Not Correlate With Patient-Reported Outcomes. Journal of Shoulder and Elbow Arthroplasty. 2020. DOI: 10.1177/2471549220901873

[23] Histologic and magnetic resonance image evaluation in acromioclavicular joint osteoarthritis. JSES International. 2020. DOI: 10.1016/j.jseint.2020.03.007

[24] Operative treatment of osteoarthrosis. Current practice and future development.. The Journal of Bone & Joint Surgery. 1994. DOI: 10.2106/00004623-199409000-00019

[25] Chapter 82 Arthritis and Arthroplasty of the Elbow. 2019.

[26] Automated classification of shoulder radiology focusing on cuff tear arthropathy and glenoid erosion using AI. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09603-5

[27] The natural history of scaphoid non-union. A review of fifty-five cases.. The Journal of Bone & Joint Surgery. 1985. DOI: 10.2106/00004623-198567030-00013

[28] Cervical fusion in rheumatoid arthritis.. The Journal of Bone & Joint Surgery. 1981. DOI: 10.2106/00004623-198163080-00003

[29] Semiconstrained Total Elbow Arthroplasty for Posttraumatic Arthritis or Deformities of the Elbow: A Prospective Study. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.03.051

[30] Osteochondritis Dissecans of the Capitellum. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546509354969

[31] Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Articular Cartilage. Part II. The Journal of Bone & Joint Surgery. 1997. DOI: 10.2106/00004623-199704000-00022

[33] Glenohumeral arthritis in the young patient. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.11.014

[34] Exfoliative cytology interpretation of synovial fluid in joint disease. The Journal of Bone & Joint Surgery. 1976. DOI: 10.2106/00004623-197658030-00019

[35] The Articular Manifestations of Periodic Disease (Familial Mediterranean Fever). The Journal of Bone & Joint Surgery. 1965. DOI: 10.2106/00004623-196547080-00016

[36] Treatment of Elbow Osteoarthritis with Arthroscopic Debridement and Intra-Articular HA Injection. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2020.12.172

[37] Contact analysis of the native radiocapitellar joint compared with axisymmetric and nonaxisymmetric radial head hemiarthroplasty. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.12.011

[38] Revisited: Walch Classification of the Glenoid in Glenohumeral Osteoarthritis. Shoulder & Elbow. 2012. DOI: 10.1111/j.1758-5740.2011.00151.x

[39] 1958 Revision of Diagnostic Criteria for Rheumatoid Arthritis. The Journal of Bone & Joint Surgery. 1959. DOI: 10.2106/00004623-195941040-00023

[40] Management of Rheumatoid Arthritis: An Overview. Cells. 2021. DOI: 10.3390/cells10112857

[41] Interobserver and intraobserver reliability of the Walch classification in primary glenohumeral arthritis. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.08.003

[42] Management of osteoarthritis - biological approaches: current concepts. Journal of ISAKOS. 2020. DOI: 10.1136/jisakos-2019-000377

[43] Treatment of Shoulder Osteoarthritis With Intact Rotator Cuff and Severe Glenoid Retroversion. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00669

[44] Osteochondritis dissecans of the capitellum. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.11.058

[45] Changing clinical patterns in rheumatoid arthritis management over two decades: sequential observational studies. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-0897-y

[46] Are bone bruises a possible cause of osteochondritis dissecans of the capitellum? a case report and review of the literature. Archives of Orthopaedic and Trauma Surgery. 2005. DOI: 10.1007/s00402-005-0018-0

[47] Reliability testing of the Larsen and Sharp classifications for rheumatoid arthritis of the elbow. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.07.074

[48] Neuropathic Arthropathy of the Shoulder. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199809000-00010

[49] Outcomes of semiconstrained total elbow arthroplasty performed for arthritis in patients under 55 years old. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.08.006

[51] Intra-articular therapy with methotrexate or tumor necrosis factor inhibitors in rheumatoid arthritis: a systematic review. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04651-5

[54] Short‐ and mid‐term results of plica excision in patients with mediopatellar plica and associated cartilage degeneration. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1125-1

[55] Interposition arthroplasty of the elbow with hinged external fixation for post-traumatic arthritis. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.11.008

[56] Classification of humeral head pathomorphology in primary osteoarthritis: a radiographic and in vivo photographic analysis. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.07.009

[57] Instability and Degenerative Arthritis of the Sternoclavicular Joint. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513498990

[59] Classifications in Brief: Walch Classification of Primary Glenohumeral Osteoarthritis. Clinical Orthopaedics & Related Research. 2017. DOI: 10.1007/s11999-017-5317-6

[60] Elbow Arthritis. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.12.014

[61] Radiographic changes at the elbow in primary osteoarthritis: A comparison with normal aging of the elbow joint. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.08.005

[64] Mid- to long-term results after bipolar radial head arthroplasty. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.05.022

[66] Surgical Management of the Rheumatoid Elbow. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200303000-00004

[68] Identifying the Location and Volume of Bony Impingement in Elbow Osteoarthritis by 3-Dimensional Computational Modeling. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.03.035

[69] Radial Nerve Palsy After Arthroscopic Anterior Capsular Release for Degenerative Elbow Contracture. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2006.11.021

[70] Primary and Posttraumatic Arthritis of the Elbow. Arthritis. 2013. DOI: 10.1155/2013/473259

[72] Shoulder Osteoarthritis. Arthritis. 2013. DOI: 10.1155/2013/370231

[73] Painful Conditions of the Acromioclavicular Joint. Journal of the American Academy of Orthopaedic Surgeons. 1999. DOI: 10.5435/00124635-199905000-00004

[74] Pyrocarbon interposition shoulder arthroplasty in young arthritic patients: a prospective observational study. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.05.044

[75] Osteoarthritis of the Elbow. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.05.001

[76] Current Concepts Review - Hallux Rigidus and Osteoarthrosis of the First Metatarsophalangeal Joint. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199806000-00015

[77] Physical Therapy Management of Patients with Osteochondritis Dissecans. Clinics in Sports Medicine. 2014. DOI: 10.1016/j.csm.2014.01.001

[78] Outcome of total elbow replacement for rheumatoid arthritis: Single surgeon's series with Souter-Strathclyde and Coonrad-Morrey prosthesis. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.09.016

[79] Treatment of Glenohumeral Osteoarthritis. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201006000-00010

[80] Surgery for Rheumatoid Arthritis—Timing and Techniques. The Journal of Bone & Joint Surgery. 1968. DOI: 10.2106/00004623-196850030-00020

[81] Radiological changes in shoulder osteoarthritis and pain sensation correlate with patients’ age. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03137-x

[82] Calcitonin treatment for osteoarthritis and rheumatoid arthritis – a systematic review and meta-analysis of preclinical data. EFORT Open Reviews. 2024. DOI: 10.1530/eor-23-0133

[83] Population prevalence of ultrasound features of osteoarthritis in the hand, knee and hip at age 63 years: the Newcastle thousand families birth cohort. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-162

[84] Double semitendinosus anterior cruciate ligament reconstruction: 10‐year results. Knee Surgery, Sports Traumatology, Arthroscopy. 1998. DOI: 10.1007/s001670050076

[85] Prevalence of MRI-detected mediopatellar plica in subjects with knee pain and the association with MRI-detected patellofemoral cartilage damage and bone marrow lesions: data from the Joints On Glucosamine study. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-292

[86] Prospective outcome assessment of arthroscopic arthrolysis for traumatic and degenerative elbow contracture. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.02.068

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