Features October 2018 Issue

Replacing Damaged Elbows

Like hips and knees, the elbow joint can be replaced. Itís not always for arthritis.

A growing population of older adults may be partly responsible for an increase in elbow replacement surgeries for fractures of the bone near the elbow. Older adults are more likely than younger people to break a bone from a fall, including the lower end of the upper arm bone (called the distal†humerus).

“In the past, the number one indication for elbow replacement surgery was inflammatory arthritis, such as rheumatoid arthritis and psoriatic arthritis,” says Arthritis Advisor Editor-in-Chief and orthopaedic surgeon Steven Maschke, MD. Improved drug treatment for these conditions has meant that fewer people end up with the severe joint damage that requires surgery.

More recently, candidates for elbow replacement have expanded to people with osteoarthritis and those with distal humerus fractures. The larger of these two groups are those with fractures. Osteoarthritis in the elbow is relatively uncommon.

Arthritic Conditions

Elbow replacement was originally developed for people with rheumatoid arthritis. With this autoimmune disease the body’s immune system attacks healthy tissue, primarily the tissue lining the joints. It usually affects multiple joints, which may include the elbows, causing pain, swelling and stiffness. If symptoms become severe and cannot be relieved with nonsurgical measures, elbow replacement becomes an option.

elbow pain

© Eraxion | Getty Images

Elbow replacement surgery can be done for people with arthritis or a fractured arm bone.

The more common type of arthritis—osteoarthritis —results from the deterioration of cartilage (which cushions the ends of bones in joints and creates a smooth gliding surface for movement), causing pain, swelling and stiffness. Weight-bearing joints, such as the hips and knees, are most susceptible.

Osteoarthritis can develop in the elbow, but it is most likely to affect people who have had a traumatic injury to the elbow or who put excess pressure on their elbows. They may include heavy machine operators, weightlifters and some athletes.

Osteoarthritis is treated with similar nonsurgical measures regardless of the affected joint. If pain and diminished mobility in the elbow become severe, a last resort is an elbow replacement.

Fracture Fix

The third and growing reason for elbow replacement is a distal humerus fracture. The upper arm bone can break near the elbow from a sudden trauma, such as a car accident. But in older adults who have weaker bones and possibly osteoporosis, the humerus can break in this location from a simple fall. With the aging of the population, the rate of bone fractures is going up, including the humerus.

Distal humerus fractures are challenging to treat. They almost always require surgery. “In older adults the bone quality may not be good enough for the traditional method of using plates and screws to fix broken bones in place,” says Dr. Maschke. In addition, the fracture may be too complex for this to work.

Research shows that older adults with a distal humerus fracture often do better with a total elbow replacement than with repairing a fracture with plates and screws.

An Option with Limitations

Elbow replacement isn’t for everyone. “The main limitation of elbow replacement surgery is the permanent lifting restriction of not more than seven pounds,” says Dr. Maschke. In addition, the implants are not likely to hold up for the several decades that would be necessary if used in a younger adult. For these reasons, elbow replacement surgery generally is reserved for older adults who don’t need to lift heavy items.

Elbow replacement can be done two ways — linked and unlinked. In the United States, the linked implant is more common. A metallic stem is anchored inside the humerus (upper arm bone) and another is inserted in the ulna (one of two bones in the forearm). They are cemented in place. The two stems are connected with a hinge in the elbow.

elbow x ray

Image courtesy of DJO Surgicalģ

Two metallic stems are inserted in the arm bones. In most cases, they are linked with a hinge.

The downside of a linked implant is the hinge, which is somewhat floppy, can stretch and cause the implant to loosen. This is the reason for the restriction against lifting anything too heavy.

With an unlinked implant, the two stems are inserted (one in the humerus and the other in the ulna) without the hinge. They are held in place by the ligaments, muscles, and other structures of the elbow. These tissues must be in good condition for this to work well. Otherwise, it can become unstable. Physical therapy to strengthen the muscles and ligaments is critical for joint stability.

Implant designs continue to evolve and improve. A relatively new innovation is a convertible implant, which is unlinked when first put in. If it becomes unstable later on, it can be revised and turned into a linked implant by adding a hinge without having to replace the entire implant.

Even newer designs under development are partial replacements. For example, just a component that fits in the humerus is inserted. The hope with these is they won’t require the same lifting restriction. And they might work for a younger, more active person who puts higher demands on the joint.

What to Expect

Most elbow replacement surgeries require a one-night stay in the hospital. A splint or half cast that immobilizes the arm is worn for about a week. After that, a removable splint is used and physical therapy begins to increase range of motion.

“We’re not trying to work on strengthening because of the lifting restriction,” says Dr. Maschke. After six weeks, the splint is no longer needed, but physical therapy continues. “By three months, people are usually doing very well,” he says.

“Pain relief is almost 100 percent with elbow replacement, especially for people with severe arthritis,” says Dr. Maschke. You’ll also get back the range of motion that allows you to do daily tasks, as long as they don’t require heavy lifting.

All surgery has risks. With elbow replacement, possible complications include infection and loosening of the implant. Elbow replacement implants have a greater tendency to wear out and loosen than implants for other joint replacements, especially if not properly protected. This may require another surgery.

The lifespan of the implant depends on a variety of factors. In general, about 90 percent of implants last for at least 10 years. “I’ve seen elbow replacements that have been in for 25 years and look great, and I’ve seen ones that have been in for five years and are loose because someone abused them,” says Dr. Maschke.

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