Elbow replacement surgery for arthritis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit



The elbow is a hinge joint consisting of three bones.

In a healthy elbow joint, the surfaces of these bones are very smooth and covered with a tough protective tissue called cartilage. Arthritis causes damage to the bone surfaces and cartilage where the three bones rub together. These damaged surfaces eventually become painful.

Several types of surgery have been used to manage arthritis of the elbow. If the arthritis primarily affects the joint between the lower end of the humerus (upper arm bone) and the head of the radius (one of the forearm bones), removal of the head of the radius may restore comfort and function to the elbow.

Joint replacement of the elbow may be of the constrained (hinge) or unconstrained (joint resurfacing) types. In the treatment of severe rheumatoid arthritis of the elbow, the constrained (or hinge) joint replacement is often preferred because it offers stability to the joint and is not dependent on ligaments, which may be weakened by the arthritis. This may not be as critical for patients who have osteoarthritis of the elbow.

Joint replacement surgery is considered when:

1. the arthritis is a major problem for the patient,
2. the patient is sufficiently healthy to undergo the procedure,
3. the patient understands and accepts the risks and alternatives,
4. there is sufficient bone and tendon to permit the surgery, and
5. the surgeon is experienced in elbow replacement surgery.
The goal of elbow replacement arthroplasty is to restore functional mechanics to the joint by removing scar tissue, balancing muscles, and inserting a joint replacement in the place of the destroyed elbow.

In elbow arthritis the joint surface is destroyed by wear and tear, inflammation, injury, or previous surgery. This joint destruction makes the elbow stiff, painful, and unable to carry out its normal functions. Elbow joint replacement can be effective primarily in the management of severe elbow involvement from rheumatoid arthritis.

After performing a clinical examination, an elbow surgeon experienced in joint replacement can determine if rheumatoid arthritis is the cause of the problem and if surgery is likely to be helpful. Patients are most likely to benefit from this surgery if they are well motivated and in optimal health.

In total elbow replacement surgery, an artificial hinge made of metal and a very durable plastic material is inserted into the joint so that the elbow can move without allowing the two forearm bones to contact the humerus. This artificial hinge is called an "implant."

The patient is first taken into the operating room and given anesthesia. After the anesthesia has taken effect, the skin around the elbow is thoroughly scrubbed and sterilized with an antiseptic liquid. A tourniquet is then applied to the upper portion of the arm to help slow the flow of blood.

An incision about six inches long is then made over the elbow joint. The incision is gradually made deeper through muscle and other tissue until the bones of the elbow joint are exposed.

One of the forearm bones, the ulna, has a projection at the end, which extends up and behind the end of the humerus. A special power saw is used to remove part of this projection.

This allows the two forearm bones to be rotated out of the way so parts of the humerus can be removed with the saw. Precision guides are used to help make sure that the cuts are made so the bones will align properly after the implant is inserted.

The middle portion at the end of the humerus is removed first.

The arm bones have relatively soft, porous bone tissue in the center. This part of the bone is called the "canal." Special instruments are used to clear some of this soft bone from the canal of the humerus. These instruments also help shape the canal to fit the shape of the implant.

Then, similar instruments are used to clear some of the soft bone and shape the canal of the ulna.

The elbow implant consists of two metal stems that are connected by a metal locking pin. This pin passes through the ends of both stems, which are lined with a strong plastic material, serving as a bearing that allows the elbow to bend. The stems are inserted into each of the two prepared canals. A special kind of cement for bones is first injected into the canals to help hold the stems in place.

When the cement is hard, the two implant parts are brought together and the pin is inserted to connect them.

If necessary, the surgeon may adjust the ligaments that surround the elbow to achieve the best possible elbow function.

When all of the implants are in place and the ligaments are properly adjusted, the surgeon sews the layers of tissue back into their proper position. A plastic tube may be inserted into the wound to allow liquids to drain from the site during the first few hours after surgery. The edges of the skin are then sewn together, and the elbow is wrapped in a sterile bandage. Finally, the patient is taken to the recovery room.

Elbow motion is started on the second day after the procedure, as soon as the incision is ready. Patients learn to do their own physical therapy and are usually discharged three to four days after surgery when they are comfortable and have a good range of passive motion. The recovery of strength and function may continue for up to a year after surgery.

As with any surgery, elbow replacement carries the risk of infection and bleeding. Also, the metal joints can loosen from the bone, which would need to be corrected with another surgery. Injury to the nerves in the elbow is also possible.

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