Definition and Overview

Total elbow replacement, or total elbow arthroplasty, is a surgical procedure that involves substituting the elbow joint with an artificial prosthetic joint composed of two metal rods or stems connected to a hinge made of metal and plastic. Total elbow replacement is not as commonly performed as hip or knee replacements with only about 3,000 people undergoing the procedure each year.

Who Should Undergo and Expected Results

There are several conditions that may prompt a patient to undergo a total elbow replacement. Arthritis, a disease of the joints, is one of the common reasons for this procedure. The classic indication is rheumatoid arthritis, a type of arthritis wherein there is inflammation and thickening of the surrounding synovial membrane. The inflammation persists for a long time, resulting in damage to and loss of cartilage. This presents as joint pain, difficulty in moving the joint, and joint stiffness. In recent years, the indications for performing total elbow replacement have expanded to include other forms of arthritis, such as degenerative osteoarthritis and post-traumatic arthritis. This surgery is considered as the last resort when all other non-invasive treatment options have been unsuccessful.

Total elbow replacement may also be performed for patients who suffer from severe injuries to the elbow joint. In cases where the elbow or one of the bones that make up the joint is severely injured or shattered, it may be difficult to put the pieces back together and restore functionality. Moreover, elbow injury can result in damaged ligaments and chronic instability, which can put the patient at risk for dislocations. In these instances, total elbow replacement may be the best option. As for the expected results, quality of life generally improves following the procedure with patients reporting long-lasting pain relief and improvement of their joint’s motion and functionality. Although patients are able to perform activities of daily living without problems, strenuous activities, such as participating in contact sports and lifting heavy objects, may have to be avoided, as these can loosen implant parts that can lead to bone fractures. Recovery after total elbow replacement is approximately 12 weeks.

How is the Procedure Performed?

Total elbow replacement is performed under general anaesthesia. To access the elbow, an incision is made at the back of the joint and the subcutaneous tissue and muscles are retracted while spurs or scar tissues surrounding the joint, if there are any, are gently removed. The humerus (the bone of the arm) and the ulna (one of bones of the forearm) near the elbow joint are then isolated before the stems of the implant are fitted on the humerus and the ulna. The implant is secured in place using bone cement and allowed to harden. Some orthopaedic surgeons advocate adding antibiotics to the bone cement to minimise infection. The muscles are then returned in place and the incision is closed.

After the surgery, the elbow may have to remain flexed for a couple of days to allow the healing of the soft tissues. Once healed, physical therapy and range of motion exercises are performed to strengthen the arm and prevent joint stiffness. Rehabilitation is vital to the success of an elbow replacement.

Possible Risks and Complications

Compared to other joints in the body that are being artificially replaced, the complication rate is highest with the elbow joint. Approximately 25% of elbow implants fail after 5 to 7 years following the procedure with the poor quality of tissues near the joint being one of the main reasons for this failure. Even with medical and technological developments, loosening of the parts of the implant and wearing out of the prosthetic joint can occur after several years. Because of this, total elbow replacement is generally not recommended for young individuals. When failure occurs, bone deficiency, specifically of the ulna, becomes a problem. For cases of elbow replacement failure, additional surgery for revision or to replace certain implant components may be necessary. In some cases, a repeat elbow replacement may have to be performed. However, succeeding elbow replacements are generally not as successful as the first one.

Infection is a dreaded complication of elbow replacement, occurring in less than 10% of patients. Superficial infections affecting only the wound are best treated with aggressive wound care and antibiotic therapy. Deeper infections involving the compartments of the arm or forearm may require repeat surgeries to remove the infected tissues (debridement), or in worst cases, removal of the elbow implant.

The nearby nerves and blood vessels may also be injured during the operation. Some nerve injuries may spontaneously improve through time. When performed properly, these complications are quite rare. Since the implant is a foreign body, the body may develop adverse reactions or allergies to it or its components. Other complications include dislocation of the elbow, weakness of the tendons of the upper extremity, fracture of the bones particularly the ulna, and joint stiffness.

Reference:

  • University of Washington Medical Center: “Total elbow joint replacement for rheumatoid arthritis: A Patient's Guide.”Sanchez-Sotelo J. The Open Orthopaedics Journal, 2011.
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