Features May 2013 Issue

A Realistic View of Rebuilding the Elbow

Once completely understood, an elbow replacement offers function and freedom.

Combing your hair. Putting the groceries away. Performing these daily tasks is often taken for granted, but when you lose function of your elbow it becomes painfully clear that the easiest tasks may be out of reach. A complicated joint, when the elbow is affected by trauma or arthritis its function deteriorates leaving many wondering if they’ll ever use their arm again.

Beyond the Hip and Knee
Fortunately, the continued evolution of joint replacement has moved beyond hip and knee joints to offer advances for those in need of a total elbow replacement. In 2010, about 3,000 people in the United States had total elbow arthroplasty surgery, according to the Agency for Healthcare Research and Quality, and the numbers are growing for those who yearn to reestablish independence.

“Those who have a total elbow arthroplasty are some of the most grateful patients due to the function they regain,” says Steven D. Maschke, MD, an orthopaedic surgeon at Cleveland Clinic. “While the results can be very successful, it’s important that patients understand the reality of what elbow replacement surgery can realistically offer them.”

Offering Your Hinge Help
Imagine your elbow as a hinge, constantly opening and closing. The average range of motion in an elbow is a 145-degree arc of motion. In those with degenerative osteoarthritis or traumatic arthritis (due to a previous fracture) of the elbow, their range of motion can be limited to just 40 degrees. It’s these patients who most benefit from a total elbow replacement, according to Dr. Maschke.

“The standard elbow replacement is completed in patients ages 65 and over who have debilitating osteoarthritis or rheumatoid arthritis, or who have suffered a fracture due to trauma. It’s not recommended for anyone who performs heavy labor or those involved in athletics due to the strict lifting restrictions it imposes after surgery,” Dr. Maschke explains. “The best candidates for surgery are more sedentary patients or those who have such debilitating pain that their options are fairly limited.”

Embracing a Lifetime Limitation
Following elbow arthroplasty, there is a lifetime lifting restriction of five to seven pounds. An elbow replacement’s goal is to recreate the joint’s function through removing damaged tissue and parts of the two arm bones—the humerus and the ulna—that meet at the elbow joint. After removing tissue and bone, the elbow joint is replaced with an artificial joint, which consists of two implants attached to the insides of the humerus and ulna. While there are various types of implants to fit joints of different sizes, all types are joined together by a metal or plastic hinge.

Currently, elbow replacement is primarily completed with the linked (coupled) or hinged implant. The replacement stems of the linked implant are placed into the humerus and ulna bones, which are kept in place with bone cement.

“Linked implants are successful in ensuring joint stability, even in the presence of severe bone loss or insufficiency in the ligaments,” says Dr. Maschke. “Unlinked implants are used less often in the United States due to complications of bone loss and soft tissue concerns in the long term.”

Regaining Motion
For a week following elbow replacement surgery, a half cast is used to aid with healing. A splint is used for the next five weeks to begin range of motion exercises. Overall, physical therapy from a strengthening perspective is limited due to the lifting restriction.

“Within six weeks, patients have regained a great deal of motion, and within three months they’ve usually reached their optimum level,” he says.

The success rate is increasing for elbow arthroplasty. “Historically, the higher complication and failure rates of elbow replacement are due to inappropriate patient selection. We need to be clear to each candidate about what a total elbow replacement can and can’t offer them,” says Dr. Maschke. “By educating patients on the real restrictions and benefits of a total elbow replacement, you can ensure a successful outcome.”