Elbow Surgery

Bo Povlsen MD PhD Consultant Orthopaedic Surgeon Guy’s Hospital, London,
Associate Professor in Hand Surgery, University of Linkoping, Sweden
Original article: 19/09/2003
Reviewed: 03/02/2010
Next review due: 03/02/2013

A total elbow replacement is predominantly a procedure, which is carried out in patients with longstanding rheumatoid arthritis. The first type of elbow arthritis surgery was carried out by excising the ends of the bones at the joint, either completely or partially, and later on by covering the remaining bone ends with muscle or tissue. These methods are still used today, but are mostly reserved for procedures where a metal and plastic replacement procedure has failed, most frequently because of persistent infection. The types of joint replacement which are currently in use have all been developed during the last 25 years and, therefore, have a much shorter total life experience than, for instance, hip, knee or shoulder joint replacements. The elbow joint is a hinge between the upper arm (humerus) and the forearm (the ulna) but due to the relatively small amount of bone which is found on the other side of the elbow joint, it has traditionally been an area that has been associated with far less satisfactory outcome than for instance hip, knee or shoulder joint replacements. In addition to the relative small amount of bone surrounding the elbow joint, one of the main problems is that the stability of the elbow joint, which often is lost through severe degenerative disease, affects the ligaments. As a result of that, the joint may cease to work as a pure hinge joint but may move sideways as well. That means that surgery for destroyed elbow joints not only has to replace the joint ends but also needs to control and reconstruct the ligaments in order to recreate a hinge joint that functions following surgery.

In my experience, however, most of the patients who come to see me want to consider a joint replacement because the range of movement in the elbow joint has gradually been lost or any attempt to bend the elbow joint is now so painful that movement is impossible. The joint replacement of the elbow is good in terms of reducing the pain. This will take place already within the first 2-4 weeks, but is also excellent in improving the ability of bending the elbow beyond what was previously possible. However, an artificial elbow joint does not guarantee any improved straightening of the elbow.

There are, in principle, two types of artificial elbow joint replacements available. One type is hinged and therefore does not need to rely so heavily on existing ligaments to stabilise the joint. The second type is loose and acts more as a surface replacement, and therefore requires intact or reconstructed ligaments to provide stability. Generally, the more there are strong and working ligaments around the elbow, the longer will the joint replacement continue to work before it eventually comes loose. The result following elbow replacement varies greatly and has been reported in some series with certain implants to have a loosening of up to 50% within a couple of years and in other series with other implants to be successful for 15-20 years in a large proportions of the patients.

If the patient and the surgeon agree that a joint replacement of the elbow would be beneficial to the patient despite the inherent risks, then most frequently these procedures are carried out under a general anaesthetic during which the blood supply to the elbow is stopped during the procedure. The procedure takes approximately two hours, during which the most significant risk is a nerve injury to the ulnar nerve (which governs some of the tendon and muscles of the hand) and after surgery a risk of infection in about 1-2%. Under normal circumstances, the patient would be allowed to start moving the elbow joint the following day and may stay in hospital for approximately a week depending on how much pain there is felt following surgery and how well progression with rehabilitation takes place. Normally within the first week, the patient should be able to reach the mouth with the operated hand. Because of the ligament and tendon surgery, there is restriction in how forceful the arm can be used for the first six weeks, but after that normal activity should be possible to be resumed. For patients who use crutches, there are specific problems as elbow joints have been seen to come loose more rapidly if the elbow joints are made to take up the full body weight through usage of crutches. This risk has to be considered prior to surgery.

In my experience, for patients who have significant pain and functional disabilities, particularly if both elbows are affected, a metal and plastic replacement joint to the elbow can add significant life quality to the patient. However, every potential patient has to appreciate that there is a much higher risk of the implant coming loose in the elbow than what is seen in hip, knee or shoulder surgery, particularly if the patient is using mobility aids. Therefore a somewhat more cautious approach than what can be adopted for hip replacement surgery is advisable. However, on the whole, elbow joint replacement surgery can be a very good operation in the correct selected patient group and most complications can be successfully treated even if the first joint replacement becomes loose. Due to its less frequent use, this operation is probably best carried out by surgeons who specialise in upper limb surgery.

Below is an account of one of my own patients in her own words. She has kindly allowed us to reproduce the follow up x-rays 9 years after the last operation.

Jean writes:

“I had my right elbow replaced in (1992) as it was too painful to move. I was in hospital for a few days followed by several weeks of intensive physiotherapy exercises. I was able to use my arm, to varying degrees, a few days after the operation and within a few months was using the arm normally and without giving it much thought. Because of the type of replacement used at that time and probably helped by an accident in late 1995, when my elbow took quite a knock, the joint had eventually became loose and moved, causing pain. It was replaced again in the early part of 2000 and has been entirely successful. In both cases, my only limitations in using the arm are those imposed by having rheumatoid arthritis in my hands, wrists and shoulders. My elbow joint is free from pain, strong and stable, with only a thin scar which no-one has ever noticed. The replacement will not allow my arm to lock into a completely straight line but have never had any need for my arm to be in that position. I can still carry a briefcase or bag and bend it to touch my shoulders and the back of my head and neck. My advice to anyone needing an elbow replacement is:

• to chose a specialist as opposed to a general orthopaedic surgeon;
• to persevere with the physiotherapy exercises in order to get the elbow moving through its full range;
• at the final out-patients visit ask the surgeon if there is anything you shouldn't do;
• and - don't be frightened to use it”.

Left: 2006 xrays (left is front view and right is side view of the elbow)











Left: 2007 xrays (left is front view and right is side view of the elbow)












Left: 2009 xrays (left is side & front view and right is side view of the elbow)






These x-rays show the right elbow joint from the front (AP) and side (lat) after the original implant was replaced in 2000 after it came loose. As can be seen from the x-rays over the subsequent 9 years there have been no loosening yet but the patient will continue to have yearly controls.

References available on request