Keyhole Surgery for Elbow Arthritis: When Can Arthroscopy Help?

Elbow arthritis can cause pain, stiffness and loss of movement. For some patients, even relatively simple activities such as reaching their mouth, washing their hair or performing work and sporting activities become difficult.

When non-operative treatments are no longer providing enough relief, surgery may be considered.

Importantly, an arthritic elbow does not always require a joint replacement.

For appropriately selected patients, keyhole surgery — known as elbow arthroscopy — can remove bone spurs, loose fragments and inflamed tissue and improve movement while preserving the natural elbow joint.

What happens with elbow arthritis?

The elbow is formed by three bones: the humerus in the upper arm and the radius and ulna in the forearm.

The surfaces of these bones are normally covered by smooth cartilage.

With arthritis, this cartilage gradually deteriorates. The body may also produce additional bone around the edges of the joint, known as osteophytes or bone spurs.

These changes can result in:

• Pain
• Loss of movement
• Difficulty fully straightening the elbow
• Difficulty fully bending the elbow
• Catching or locking
• Grinding or clicking
• Loose pieces of bone or cartilage within the joint

Elbow arthritis is particularly common in people who have performed years of heavy manual work, weight training or repetitive loading of the elbow. It can also occur following a previous fracture or significant elbow injury.

Why does an arthritic elbow become stiff?

Interestingly, the amount of stiffness does not always correspond directly with the amount of cartilage wear.

Bone spurs can develop at the front and back of the elbow and physically block movement.

For example, a bone spur at the back of the elbow can prevent the elbow from fully straightening, while changes at the front of the joint can restrict bending.

The joint capsule — the soft tissue surrounding the elbow — can also become thickened and contracted.

This distinction is important because an elbow that is painful primarily because of severe cartilage loss is a different problem from an elbow that is painful and stiff because of bone spurs and mechanical impingement.

The second situation is often particularly suitable for arthroscopic treatment.

What is elbow arthroscopy?

Elbow arthroscopy is a form of keyhole surgery.

A small camera is introduced into the elbow through a series of small incisions. Specialised instruments can then be used to treat problems within the joint.

Depending on the individual elbow, the procedure may involve:

• Removing bone spurs
• Removing loose bodies
• Removing inflamed or abnormal tissue
• Releasing a tight joint capsule
• Smoothing areas of damaged bone or cartilage
• Improving the space available for the elbow to bend and straighten

This procedure is sometimes referred to as an arthroscopic elbow debridement or arthroscopic osteocapsular arthroplasty.

The aim is to improve pain and movement without replacing the elbow joint.

Who is a good candidate for keyhole surgery?

Elbow arthroscopy tends to work best when there is a significant mechanical component to the symptoms.

For example, you may have:

• Difficulty fully straightening the elbow
• Difficulty bending the elbow
• Pain at the extremes of movement
• Catching or locking
• Loose bodies within the joint
• Prominent bone spurs
• Stiffness that interferes with work, exercise or everyday activities

Patients with mild to moderate arthritis but significant stiffness and bone spur formation can sometimes achieve substantial improvement.

It can be particularly attractive in younger or more active patients, where preserving the natural elbow joint is desirable.

When is keyhole surgery less likely to help?

Elbow arthroscopy cannot restore cartilage that has completely worn away.

If the joint has advanced arthritis with extensive cartilage loss and pain throughout the entire range of movement, simply removing bone spurs may not adequately address the underlying problem.

This is an important distinction.

A patient whose main complaint is:

“My elbow hurts when I try to fully straighten it”

may have a mechanical block that responds well to arthroscopic surgery.

A patient whose elbow:

“Hurts constantly whenever I move it”

may have more advanced joint surface disease.

Imaging and examination help determine which problem is dominant.

Do I need a CT scan?

X-rays are usually the starting point for assessing elbow arthritis.

A CT scan can be particularly useful when surgery is being considered.

CT imaging provides a detailed three-dimensional assessment of the elbow and can demonstrate:

• The location of bone spurs
• Loose bodies
• Areas of joint narrowing
• Previous fractures or deformity
• The amount of bone that may need to be removed

This can be very useful when planning arthroscopic surgery.

What should I try before surgery?

Having arthritis on an X-ray does not automatically mean you need an operation.

Treatment may initially include:

• Activity modification
• Physiotherapy
• Maintaining elbow movement
• Appropriate pain relief or anti-inflammatory medication
• Corticosteroid injection in selected patients
• Modification of gym, sporting or occupational activities

If symptoms remain manageable, there is usually no urgency to proceed with surgery.

Surgery becomes more reasonable when pain or stiffness is having a significant impact on your quality of life despite appropriate non-operative treatment.

What happens during the operation?

Elbow arthroscopy is usually performed under a general anaesthetic.

Several small incisions are made around the elbow, allowing a camera and specialised instruments to enter different parts of the joint.

Bone spurs can be carefully removed with a small burr.

Loose pieces of bone or cartilage can be removed.

If the capsule has become very tight, it can be released to improve movement.

The exact procedure is tailored to the abnormalities present in your elbow.

What does recovery look like?

One advantage of arthroscopic treatment is that movement can usually begin relatively early.

Unlike tendon or ligament repair surgery, there is generally not a repaired structure that needs to be protected for several months.

The emphasis after surgery is therefore often on regaining and maintaining the movement achieved during the operation.

Physiotherapy may begin early and usually concentrates on:

• Restoring elbow bending
• Restoring elbow straightening
• Reducing swelling
• Gradually rebuilding strength
• Returning to normal use of the arm

The elbow will initially be swollen and uncomfortable, and improvement is progressive rather than immediate.

Light everyday activities usually return relatively quickly, while heavy lifting, gym work and strenuous manual activities take longer.

How much movement will I regain?

This depends on how stiff the elbow was before surgery and what is causing the restriction.

If movement is being physically blocked by bone spurs and a contracted capsule, removing these restrictions can produce a meaningful improvement.

However, the aim is improvement rather than necessarily restoring a completely normal elbow.

Patients with longstanding arthritis may continue to have some loss of movement after surgery.

The most important outcome is usually achieving a comfortable and functional range of movement for everyday activities.

Will arthroscopy cure my arthritis?

No.

This is an important expectation.

Arthroscopy can remove the consequences of arthritis — such as bone spurs, loose bodies, impingement and capsular stiffness — but it cannot replace lost cartilage.

The underlying arthritic process therefore remains.

Some patients achieve many years of improvement following surgery. In others, arthritis may gradually progress and symptoms can return.

Having arthroscopic surgery does not prevent other treatments being considered in the future if they eventually become necessary.

What are the risks?

Elbow arthroscopy is a specialised procedure because several important nerves and blood vessels run close to the joint.

Potential complications include:

• Infection
• Bleeding
• Temporary or permanent nerve injury
• Persistent stiffness
• Recurrent stiffness
• Persistent pain
• Incomplete improvement in movement
• Further progression of arthritis
• The need for additional surgery

Nerve injury is an important consideration in elbow arthroscopy because of the proximity of the ulnar, radial and median nerves to the operative field.

Your individual risks depend on the severity of the arthritis, previous surgery or injuries, elbow anatomy and the extent of the procedure required.

What about elbow replacement?

Total elbow replacement can be an excellent operation in appropriately selected patients with severe arthritis.

However, it comes with important long-term restrictions, particularly regarding repetitive or heavy lifting.

For this reason, elbow replacement is generally reserved for patients with advanced painful arthritis where joint-preserving options are unlikely to provide sufficient improvement.

In younger or physically active patients with reasonable preservation of the joint surfaces, an arthroscopic procedure may allow us to improve symptoms while preserving the natural joint.

The bottom line

Keyhole surgery can be an excellent treatment for the right type of elbow arthritis.

It is particularly useful when symptoms are caused by:

Bone spurs, mechanical impingement, loose bodies and loss of movement.

The operation can remove these mechanical restrictions, release a tight joint and improve the functional range of movement while preserving the natural elbow.

However, arthroscopy does not create new cartilage and cannot completely reverse advanced arthritis.

The key is therefore determining what is actually causing your symptoms.

For patients with a painful, stiff elbow but reasonably preserved joint surfaces, arthroscopic debridement and removal of bone spurs can provide a valuable middle ground between ongoing non-operative treatment and more extensive surgery such as elbow replacement.

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