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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Synonyms: total elbow arthroplasty, endoprosthetic elbow replacement
Unlike hip and knee joint replacements, which are performed thousands of times per year within the NHS, elbow joint replacement is a more recent and much less common operation. Although the number performed remains small it 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.
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) or unlinked, depending on the type of replacement.
Joint replacement surgery is performed when other interventions, medical and surgical, will not offer a satisfactory outcome. Underlying pathology includes:
- Rheumatoid arthritis (RA).
- Complex fracture of the elbow, 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. 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.
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.
There are risks attached to any form of surgery:
- 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.
- Fracture of bone during surgery.
- Dislocation of the prosthesis.
- Loosening of the implant over time.
- Allergic reaction to the implant.
- Fracture of the prosthesis. This is uncommon but if it occurs, results of revision surgery are reasonably satisfactory.
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.
Choice of prosthesis
There has been criticism of joint replacement surgery 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. A similar register is under consideration in Scotland.
Elbow replacement surgery provides good to excellent results for most patients.
Further reading and references
Shoulder and elbow replacement; Arthritis Research UK
Degreef I; Elbow arthroplasty: where are we today? A narrative review. Acta Chir Belg. 2016 Apr116(2):73-80. doi: 10.1080/00015458.2016.1147246.
Jenkins PJ, Watts AC, Norwood T, et al; Total elbow replacement: outcome of 1,146 arthroplasties from the Scottish Arthroplasty Project. Acta Orthop. 2013 Apr84(2):119-23. doi: 10.3109/17453674.2013.784658. Epub 2013 Mar 14.
Inagaki K; Current concepts of elbow-joint disorders and their treatment. J Orthop Sci. 2013 Jan18(1):1-7. doi: 10.1007/s00776-012-0333-6. Epub 2013 Jan 11.
Fajardo M, Kwon YW; The rise of the metal elbow. Bull Hosp Jt Dis (2013). 201371(1):24-31.
Utukuri MM, Goddard NJ; Haemophilic arthropathy of the elbow. Haemophilia. 2005 Nov11(6):565-70.
Choo A, Ramsey ML; Total elbow arthroplasty: current options. J Am Acad Orthop Surg. 2013 Jul21(7):427-37. doi: 10.5435/JAAOS-21-07-427.
Foruria AM, Sanchez-Sotelo J, Oh LS, et al; The surgical treatment of periprosthetic elbow fractures around the ulnar stem following semiconstrained total elbow arthroplasty. J Bone Joint Surg Am. 2011 Aug 393(15):1399-407. doi: 10.2106/JBJS.J.00102.
Total Elbow Arthroplasty; Wheeless' Textbook of Orthopaedics