The elbow consists of the upper arm bone ('humerus') and two bones in the forearm ('ulna' and 'radius'). The elbow works in two parts. One part acts as a hinge enabling you to bend and straighten the elbow. The second part provides rotation or twisting of your forearm.
Joint replacement surgery is performed when other interventions, medical and surgical, will not offer a satisfactory outcome. The principle reasons for requiring an elbow replacement are:
- Rheumatoid arthritis (RA)
Complex fracture of the elbow that cannot be satisfactorily fixed with plates and screws, even in the elderly.
The indication for elbow replacement surgery can be summarised as severe pain with radiological changes of joint destruction in the presence of failed conservative treatment. The commonest reason for requiring and elbow replacement is RA. Before an elbow replacement the disease process of the RA should be under control.
Types of Elbow Replacement
There are many types of elbow replacements. We use the Coonrad-Morrey elbow replacement. This is a hinged implant that is tried and tested and has long term published outcome data. A recent review of the English language literature on total elbow arthroplasties suggests that linked hinge implants restore a better arc of movement, may return a higher proportion of good and excellent results and may have a lower rate of radiological loosening.
A Coonrad-Morrey Total Elbow Replacement
What does this involve?
This involves removing the arthritic elbow joint and replacing it with a metal hinge in two parts linked together with a plastic bushing and metal pin. The results of elbow replacement are not as reliable as those of hip and knee replacements with 10 year survival rates of approximately 90 %. That means that by 10 years after the original operation up to 10% of patients will have required revision surgery.
Following recovery from elbow replacement surgery lifting with the elbow should always be limited to less than 10 lbs or 4.5 KG of weight.
The surgery is usually undertaken under a general anaesthetic with you lying on your side. There is an incision on the back of the elbow over the triceps muscle. The tendon is then split or lifted off to allow access to the joint. The elbow joint is then removed and the elbow replacement is fixed in place with specialised bone cement as is used in hip and knee replacement surgery.
The two stems are joined with the hinge mechanism. The wound is closed, a dressing applied and a bulky bandage is applied to limit mobility initially. You will usually be discharged the following day with a sling.
Post Operative Protocol– Total Elbow Replacement
- A dressing and padded bandage is applied after the operation.
- Keep the arm elevated in a Bradford type sling or on pillows to reduce swelling
- Start moving the finger and wrist joints immediately to prevent stiffness
- Take painkillers before the anaesthetic wears off and as necessary thereafter. You will need regular pain killers for the first 1-2 weeks and then before and after physiotherapy
- You will be discharged home once your pain is under control and an x ray has been taken. You will be given a sling, this should be worn when you are “out and about”.
- Continue to keep the arm elevated on pillows whenever possible with your hand and wrist above the level of your heart. You must exercise the fingers and wrist to improve swelling and reduce swelling. You may start to gently move the elbow as pain and the bandage allow. You may bend the elbow gently up within the constraints placed by the bulky bandage dressings and allow gravity to straighten it. You will be shown exactly how to do this by your physiotherapist before discharge.
- Within the first 2week you will be seen in clinic for a wound check and removal of the staples .This follow up appointment will be made on the day following surgery.
- Xrays may be taken
- The Physiotherapist/Hand Therapist will see you, exercises will be demonstrated.
- Further review in clinic to ensure satisfactory progress
- Exercises to continue, gradually increasing range of movement and start triceps strengthening
- Further clinic review with x-rays
- Improvements in range of motion and strength can occur up to 1 year. The most marked improvement in pain and movement occur over the first 6 months.
What are the risks and potential complications of elbow replacement surgery?
The majority of patients are very satisfied with the outcome of surgery. Whilst uncommon, all surgical procedures are associated with some risks. Every effort is made to minimize these to ensure the best possible outcome from your surgery.
Stiffness : your new elbow will not bend or straighten as much as a normal elbow.
Infection : This may be a superficial or deep infection. The risk is between 2 and 8 %. An infection may require antibiotics or further surgery including revision/redo surgery.
Swelling, Stiffness and Scar Pain : this is a major operation and there will be significant swelling around the elbow and also the hand and wrist. The elbow will be quite stiff initially and gradually free up in the months after surgery. This will require physiotherapy and a high degree of compliance from the patient. Most elbow replacements do not allow the arm straighten fully.
This can be the tendon triceps tendon repair(2-8%) or skin and soft tissue healing problems. This may require further surgery. Smokers and those with diabetes or taking steroids and immunosuppressive medication such as methotrexate are more prone to this.
Nerve injury: the ulnar nerve is commonly bruised after surgery and the patient experiences a temporary numbness and nerve dysfunction. Approximately 5 % will experience severe symptoms and 1-2 % persistent symptoms.
Loosening : with time the joint will loosen and wear out. Approximately 10 -15 % at 10 years will show signs of loosening.
Fracture or break of the bone around the new joint: this can occur at the time of surgery or more commonly years later if you were to have a fall and land awkwardly on your arm/elbow. This often requires further surgery.
Fracture of the metal replacement or Bushings Wear : humeral breakage has been reported in 0.6% of patients by 8 years and ulnar component in 1.2% by 4.5 years. The plastic bearings will wear out with time and may need to be replaced. This can occur in 1-6% of patients by 8 years.
CRPS : complex regional pain syndrome, this is an uncommon but serious complication. It can on rare occasions leave you with a less function in the hand with on-going pain stiffness and swelling.
In addition there are complications related to the anaesthetic an surgery including chest infection, blood clots in legs ( DVT) and pulmonary embolism (PE).