Total Elbow Replacement
The elbow is a hinge joint which is made up of three bones:
- The humerus (upper arm bone)
- The ulna (forearm bone on the pinky finger side)
- The radius (forearm bone on the thumb side)
The surfaces of the bones where they meet to form the elbow joint are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily. A thin, smooth tissue called synovial membrane covers all remaining surfaces inside the elbow joint. In a healthy elbow, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost any friction as you bend and rotate your arm.
Muscles, ligaments, and tendons hold the elbow joint together.
The main structures of the elbow when viewed from the side.
In total elbow replacement surgery, the damaged parts of the humerus and ulna are replaced with artificial components. The artificial elbow joint is made up of a metal and plastic hinge with two metal stems. The stems fit inside the hollow part of the bone called the canal.
There are different types of elbow replacements, and components come in different sizes. There are also partial elbow replacements, which may be used in very specific situations. A discussion with your doctor will help to determine what type of elbow replacement is best for you.
Several conditions can cause elbow pain and disability, and lead patients and their doctors to consider elbow joint replacement surgery.
This is a disease in which the synovial membrane that surrounds the joint becomes inflamed and thickened. This chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain, and stiffness.
Rheumatoid arthritis is the most common form of a group of disorders termed “inflammatory arthritis.”
Osteoarthritis (Degenerative Joint Disease) Osteoarthritis is an age-related, “wear and tear” type of arthritis. It usually occurs in people 50 years of age and older, but may occur in younger people, too. The cartilage that cushions the bones of the elbow softens and wears away. The bones then rub against one another. Over time, the elbow joint becomes stiff and painful.
This type of arthritis can follow a serious elbow injury. Fractures of the bones that make up the elbow, or tears of the surrounding tendons and ligaments may cause damage to the articular cartilage over time. This causes pain and limits elbow function.
A severe fracture of one or more bones that make up the elbow is another common reason people have elbow replacements. If the elbow is shattered, it may be very difficult for a doctor to put the pieces of bone back in place. In addition, the blood supply to the bone pieces can be interrupted. In this type of case, a surgeon may recommend an elbow replacement. Older patients with osteoporosis (fragile bone) are most at risk for severe elbow fractures.
In addition, some fractures do not heal well and may require an elbow replacement to address continuing problems.
Instability occurs when the ligaments that hold the elbow joint together are damaged and do not work well. The elbow is prone to dislocation. Chronic instability is most often caused by an injury.
Preparing for Surgery
If you decide to have elbow replacement surgery, your orthopaedic surgeon may ask you to schedule a complete physical examination with your family physician several weeks before surgery. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process.
Many patients with chronic medical conditions, like heart disease, must also be evaluated by a specialist, such a cardiologist, before the surgery.
Be sure to talk to your orthopaedic surgeon about the medications you take. Some medications may need to be stopped before surgery. For example, the following over-the-counter medicines may cause excessive bleeding and should be stopped 2 weeks before surgery:
- Non-steroidal anti-inflammatory medications, such as aspirin, ibuprofen, and naproxen sodium
- Most arthritis medications
If you take blood thinners, either your primary care doctor or cardiologist will advise you about stopping these medications before surgery.
Making simple changes in your home before surgery can make your recovery period easier.
For the first several weeks after your surgery, it will be hard to reach high shelves and cupboards. Before your surgery, be sure to go through your home and place any items you may need afterwards on low shelves.
When you come home from the hospital, you will need help for a few weeks with some daily tasks like dressing, bathing, cooking, and laundry. If you will not have any support at home immediately after surgery, you may need a short stay in a rehabilitation facility until you become more independent.
Before Your Operation
You will most likely be admitted to the hospital on the day of your surgery. After admission, you will be taken to the preoperative preparation area and will meet a doctor from the anesthesia department.
You, your anesthesiologist, and your surgeon will discuss the type of anesthesia to be used. In most total elbow replacement surgeries, a general anesthetic that puts you to sleep for the entire operation is used.
To reach the elbow joint, your surgeon will make an incision (cut), usually at the back of the elbow. After making the incision, your surgeon will gently move muscles aside to get access to the bone. After removing scar tissue and spurs around the joint, your surgeon will prepare the humerus to fit the metallic piece that will replace that side of the joint. The same preparation is done for the ulna. The replacement stems are placed into the humerus and ulna bones, and kept in place with a bone cement. The two stems are connected by a hinge pin. After the wound is closed, a padded dressing is then placed to protect the incision while it heals.
Some surgeons will place a temporary tube in the joint to drain the surgical fluid. This tube can be easily removed in your hospital room within the first few days after surgery.
The metal replacement parts are made of chrome-cobalt alloy or titanium and there is a liner made of polyethylene (plastic). The bone cement is made of polymethylmethacrylate (acrylic, a type of plastic).
The next step is to determine the component position and soft tissue balance, to achieve optimum results for the patients.
There are several advantages of the CAS:
- Real time assessment of tissue balancing at any angle of flexion with patella in place as compared to conventional TKR where tensioning devices can be used in zero and 90° only. This calculation of soft tissue tension aids a surgeon in giving a perfectly balanced knee .
- Accurate restoration of mechanical limb axis.
- Reduced blood loss .
- Decrease in incidence of fat embolism due to extramedullary instrumentation.
- Surgeon is more in control and has power to correct any errors before attempting any cuts.
Your medical team will give you several doses of antibiotics to prevent infection. Most patients are able to eat solid food and get out of bed the day after surgery. You will most likely stay at the hospital 2 to 4 days after your surgery.
After surgery, you will feel some pain, but your surgeon and nurses will provide medication to make you feel as comfortable as possible. Talk with your surgeon if postoperative pain becomes a problem.
A careful, well-planned rehabilitation program is critical to the success of an elbow replacement. You will be taught some exercises for your hand and wrist to avoid stiffness and help to control swelling. You will do gentle elbow range-of-motion exercises as the incision heals. Your doctor may prescribe therapy or may teach you how to do the exercises yourself.
You will most likely not be allowed to put any weight on your arm or push against resistance with your hand until about 6 weeks after your surgery.