Elbow joint replacement

Synonyms: total elbow arthroplasty, endoprosthetic elbow replacement

What is elbow joint replacement?

Unlike hip and knee joint replacements, which are performed thousands of times per year within the NHS, elbow joint replacement is a much less common operation. Although the number performed remains small it is growing and is regarded as a well-established surgical procedure. However, not all orthopaedic units will perform this surgery.

Surgical techniques to reconstruct or replace the elbow joint are becoming increasingly effective. Debridement techniques, including open or arthroscopic Outerbridge-Kashiwaghi procedure, often delay joint replacement. Implants for joint arthroplasty focus on the ulna-humeral joint; however, there is a trend towards total joint replacement including the radiocapitellar joint.¹

A total elbow replacement is made up of metal and plastic parts and replaces the joint between the humerus and ulna. There are two metal stems that fit into the bone cavity of the upper and lower arm and these are usually fixed into place by using bone cement. The two metal stems are either linked (like a hinge),unlinked or convertible, depending on the type of replacement.²

Reasons for elbow joint replacement (indications)^{3 4}

Joint replacement surgery is performed when other interventions, medical and surgical, will not offer a satisfactory outcome. Underlying pathology includes:

• Osteoarthritis.

• Rheumatoid arthritis (RA).

• Complex fracture of the elbow or distal humerus fractures, even in the elderly.

• Severely damaged or torn soft tissues in the elbow, resulting in instability.

• Malignancy in or around the elbow.

• Poor results from previous elbow surgery.

Amongst those who get severe damage to the elbows are haemophiliacs.⁵ Osteoarthritis follows recurrent haemarthrosis. Anyone who has taken blood from a person with haemophilia will have noticed that extension of the elbow is usually well short of 180°.

Indication for operation can be summarised as severe pain with radiological changes of joint destruction in the presence of failed conservative treatment. The most common underlying pathology is RA. Before operation the disease process of the RA should be under control.

Pre-operative assessment

This is as for most surgery. PA and lateral X-rays of the joint are required and the usual blood tests are performed. In elderly patients the routine will include CXR and ECG. Those with haemophilia will need appropriate boosting of factor VIII.

Complications of elbow joint replacement⁶

There are risks attached to any form of surgery:

• Haemorrhage.

• Infection.

• Thromboembolism - less common with upper limb surgery.

There are specific risks to this operation:

• Nerve damage during surgery, especially the ulnar nerve.

• Blood vessel damage during surgery.

• Haematoma formation (around 5%) - associated with infection and further surgery.⁷

• Fracture of bone during surgery.

• Dislocation of the prosthesis.

• Aseptic loosening of the implant over time.

• Allergic reaction to the implant.

• Fracture around the prosthesis. This is uncommon but if it occurs, results of revision surgery are reasonably satisfactory.⁸

Postoperative management

The patient will stay in hospital for about three or four days. A splint may be used after surgery to help stabilise the elbow.

• Physiotherapy starts with gentle flexing exercises. Patients who have a splint typically start therapy a few weeks later than those who do not.

• The patient will need help with everyday activities, such as driving, shopping, bathing, meal preparation and household chores, for up to six weeks.

• Some patients may begin to regain function of the elbow as soon as 12 weeks after surgery, although additional recovery can take up to a year.

• The patient should not lift more than about 2.5 kg with the arm which has had the surgery, even when fully recovered.

A 2022 European survey of specialist elbow surgeons revealed that postoperative immobilisation of the elbow was advised by half of respondents when using the triceps-sparing approach (52%), and even more with the triceps-detaching approach (65%). Postoperative passive movement of the elbow was allowed in the triceps-sparing approach (91%) and in the triceps-detaching approach (87%). Most respondents gave recommendations on weight bearing (91%) or axial loading (76%) by the affected elbow, but there was significant variation indication a need for clinical guidelines.⁹

Choice of prosthesis

Total elbow prostheses have evolved over the years and now include the linked, unlinked, and convertible types.⁶

There has been criticism of elbow joint replacement surgery in the past because of poor comparisons between the various types of prostheses that are commercially available. There is now a national joint register for England, Wales and Northern Ireland.² A similar register is under consideration in Scotland. Elbow arthroplasty has now become a more reliable option, particularly for distal humerus fractures.¹⁰

There is currently limited evidence on the safety and efficacy of lateral elbow resurfacing for arthritis, therefore the National Institute for Health and Care Excellence (NICE) does not recommend that it should be used unless there are special arrangements for clinical governance, consent, and audit or research.¹¹

Prognosis

Elbow replacement surgery provides good to excellent results for most patients with around 80% of patients having an excellent outcome at 5 years.¹² For distal humerus fractures in the elderly total elbow arthroplasty gives substantially better results than open reduction and internal fixation.⁴

Evidence suggests that centres with high volumes of patients have a lower revision rate than those with low volumes, supporting centralisation of elbow arthroplasty.¹³