Elbow Replacements
ELBOW REPLACEMENT ARTHROPLASTY
The indications for total elbow joint replacement include relief of pain and restoration of stability of the elbow joint. Patients that are considered for surgery typically have one of the following characteristics: Rheumatoid Arthritis (RA), Osteoarthritis (OA), Post-Traumatic Arthritis (PTA), ankylosis (zero motion of the elbow joint), or acute intra-articular fractures.
The primary use of the elbow joint is to position the hand in space for functional use such as eating and grooming. However, the elbow joint may also function as a weight bearing joint for those patients who require the use of a cane or walker for ambulation. Adequate hand and wrist function is a pre-requisite before considering total elbow joint replacement.
The contraindications for total elbow arthroplasty include: recent sepsis (infection) of the elbow joint, charcot elbow (neuropathic joints), soft tissue injuries with massive bone and soft tissue loss, neurologic injuries, non-compliant patients or patients with unrealistic expectations or goals, and obesity.
The components of the total elbow arthroplasty are typically made of titanium and a plastic bearing system made of ultra-high molecular weight polyethylene. An incision is made along the back of the elbow and the ulnar nerve (the "funny bone" nerve) on the posterior medial aspect of the elbow is moved to a new position more anterior on the elbow so that it will not interfere with the motion of the total elbow arthroplasty. Typically, the components are cemented into the humerus bone of the upper arm and the ulna bone of the forearm. Careful placement of the components and balancing the soft tissues around the elbow is important. Typically, the most common implants used are classified as semi-constrained which means they have some "play" or toggle which is felt if the elbow is moved from side to side. This is a feature of the implant design which minimizes the stress to the bone cement interface and may help to prevent loosening of the total elbow arthroplasty.
After surgery, an ice bladder is incorporated into the dressing with a posterior splint for the first week to help with reducing swelling and assist with pain relief. During the first 2 weeks after surgery, finger exercises and finger range of motion is done by the patient. From week 2 to week 6 after surgery, a custom posterior splint made by the occupational therapist is worn by the patient. During this time, the patient will work closely with the occupational (hand) therapist to restore elbow motion. At 6 weeks after surgery, gradual strengthening exercises are begun and the posterior splint is discarded. Typically, at 6 weeks after surgery is when most patients can safely return to driving their automobile. Full recovery takes about 3 months.
The artificial elbow is considered successful by more than 90% of patients who have elbow joint replacement. As with all major surgical procedures, complications can occur. The most common complications include: infection, loosening, and nerve or blood vessel injury. Furthermore, while the expected life of the total elbow replacement components is difficult to estimate, it is finite. Excessive loading through patient weight, activity or occupation can place significant forces on the total elbow prosthesis and can cause loosening or failure of the device. However, with realistic functional expectations in the performance of the activities of daily living, the components can last 10 years or more before needing to be replaced.
Christopher Brian, MDPanorama Orthopedics & Spine Center
