Total elbow replacement

What is Total elbow replacement?

Elbow is a complex joint where the hinge part of it helps in bending and straightening your arm and is also essential for rotation movement (turning palm towards ceiling and floor).  Total elbow joint replacement is a surgical procedure in which the entire elbow joint is replaced by an artificial joint. The artificial joint is made of metal rods and plastic hinge. The damaged parts of the humerus (upper arm) and ulna (bone of forearm) that form the elbow are replaced by this artificial joint. The implants are usually made of cobalt-chromiom alloy and polyethylene. Elbow replacement is not as common as knee or hip replacement. It is performed for most debilitating pathologies in which elbow joint is extensively damaged. It is recommended mostly after the age of 65 years and selected cases of debilitating arthritis in young people.

 

What are the indications for the procedure?

Total elbow replacement is indicated in

  • Rheumatoid arthritis in which arthritic changes cause functional loss, pain and instability in elbow joint in stages 3- 5, usually in old patients above the age of 65 years.
  • Osteoarthritis in patients above the age of 65 years
  • Severe fractures where bones in the elbow are broken in many pieces
  • Fracture in elderly people who have poor quality bone
  • Chronic instability with arthritis
  • Reconstruction after removal of a tumour in the affected area.

 

What are the benefits?

The benefits of total elbow replacement are-

  • Pain relief
  • Stable arm
  • Increase in the range of motion of the joint.
  • Improvement in function and quality of life

 

What are the risks?

Total elbow replacements possess risks like other surgeries. These are –

  • Infection (1-5%)– infection may develop in the wound or deep around artificial components. It can occur anytime after surgery even years after surgery. Antibiotics are prescribed to treat minor infections. Deep and major infections may call for the removal of the components.
  • Injury to tendons, nerves and blood vessels– during surgery, the nerve and blood vessels may get injured. However, it happens rarely (<1%).
  • Stiffness,
  • Misalignment of implants and dislocation
  • Lengthening/shortening
  • Broken bone-the bone may get broken or fractured when implants are inserted in them.
  • Wound healing– wound healing may get delayed. Scars may develop tenderness if not proper care is not taken.
  • Allergic reaction – your body may react against artificial components and produce allergic reactions.
  • Implant problems– wearing of the implant may happen and the components may get loosened. This calls for their replacement and you may require additional surgery if the implant break or wears down excessively.
  • Implants usually last for 10-20 years, however gives a good quality of life during that period. Patients will need a revision total elbow replacement after that time, the risks associated with revision surgery are more.
  • Thrombosis and blood clots

 

How should I prepare for the procedure?

If you have selected to under total elbow replacement surgery, you should be prepared for the following-

  1. Before surgery, your surgeon will investigate your general condition through certain tests such as blood tests, electrocardiogram or chest X-ray to rule out any health risks. This helps to rule out any possible risks of surgery such as bleeding, heart diseases etc.
  2. It is advisable to inform your surgeon about any medications or supplements (esp. Blood thinners) you are taking. He may ask you to stop them before the surgery as they may complicate the operation.
  3. If you are a smoker, you should stop smoking at least two weeks before the operation. Smoking increases the risk of chest and wound infection. It also affects your recovery process after the surgery by slowing it down.
  4. Some patients require help for household activities such as bathing, dressing, laundry and cooking for around six weeks.
  5. Any infection in the body including common cold or a cough should be cleared up before the operation.
  6. You should also stop eating or drinking 8 hours before the operation.
  7. Positive attitude towards the operation and your condition are necessary for the success of the surgery. This will help you for better health benefits and faster recovery.

 

How is it performed?

  • The patient is admitted to the hospital on the day of operation and he may have to stay in the hospital for 2-3 days after the operation.
  • In general anaesthesia, the patient does not feel anything and sleeps throughout the operation. In local anaesthesia, the patient remains awake during the operation, but he cannot feel whatever is happening in the surgical area. Your surgeon can select the combination of both local and general anaesthetic.
  • Positioning- after anaesthesia, your surgeon will give you antibiotics as a precautionary step to avoid infection during and after the surgery. Your surgeon will place you in the following positions-
  1. Supine position- in this position, you will lie flat on your back. In this position, the surgeon will take care of your spine and other pressure points to be padded and protected after positioning.
  2. Lateral decubitus position- in this position, the patient lies on the operating table sidewise.
  • A tourniquet is tied around your upper arm and the arm is placed in an arm holder to keep the arm in its proper position during the entire operation. The shoulder and upper body are wrapped in sterile surgical drapes.
  • Procedure- after marking the surgical area, your surgeon will make a cut in the elbow usually at the back side. After this, he will gently move the muscles and subcutaneous fat to a side to view the bone. He will remove the scar and damaged tissues and bone spurs around the joint. Then, he will fit a metal rod with cement in to the humerus (upper arm) and the ulna (a forearm bone). These metallic rods are cemented to the bone with bone cement. A hinge made of plastic connects the two pieces. Then, the wound is closed with absorbable sutures after repositioning the muscles in their normal position. It is then covered by a padded dressing which protects the wound during healing.
  • Your surgeon will take 2-3 hours to complete the operation.

 

What happens after surgery?

  • The local anaesthetic/block usually wear off in 4-10 hours after the surgery; the patient is encouraged to take painkillers before they can experience pain. This blocks the sensation of pain and discomfort caused by the operation.
  • A sling is applied on the elbow in order to give rest to the joint and avoid any further injury to the joint.
  • You can apply ice to relieve pain and you have to keep the elbow slightly elevated to avoid swelling.
  • Before discharge, you may see a physiotherapist, who will teach you gentle exercises of your shoulder, fingers and wrist. You may be able to start these gentle exercises on the day of your operation and they are essential to reduce stiffness and pain.
  • You can use your arm to do light activities (writing, using keyboard etc) that don’t cause excessive pain or discomfort.
  • The patient is reviewed in clinic around 2 weeks following the operation for wound check and physiotherapy.
  • The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
  • You could start gentle range of movement (ROM) exercises at 3 weeks and progress to more strenuous activities around six weeks. This will be guided by your surgeon and is based on radiographic (X-ray) and healing of other pathologies in this area. It is advisable to avoid strenuous activities or any injury to the affected arm for 3 months.
  • No lifting of heavy objects (> 10 lbs) for life.
  • No tennis, throwing activities or use of vibrating tools for life.

What are the results of the operation?

The outcome of the surgery is good with minimal serious complications (<5%). The outcome following this surgery depends on grade of arthritis, associated pathologies, chronicity of the problem, treatment involved and adherence to physiotherapy.

 

When can I return to driving and work?

You can get back to work in 2-4 weeks if you have a desk job, however might take a little bit longer if your job involves physical work. You should be able to resume driving in 4-6 weeks. The above time line could vary based on the severity of injury and the treatment modality.  Your physician will be able to advise you.

 Total_elbow_replacement

  1. An 80 year old lady with severe arthritis affecting her elbow joint presented with severe pain, stiffness and loss of function
  2. She had a total elbow replacement that relieved pain, restored range of movement and function.

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