Total Elbow Arthroplasty
Description
Total Elbow Arthroplasty (TEA) is a procedure which replaces the damaged joint surfaces of the elbow with a prosthesis (replacement joint). The elbow joint is a hinge joint which is commonly affected in conditions such as Rheumatoid Arthritis, Osteoarthritis and Traumatic Arthritis. The joint is composed of the joint surfaces of the Humerus (upper arm bone), Radial and Ulnar bones (Forearm bones). The procedure primarily aims to relieve pain and return functionality and range of movement to the affected joint. Risks of TEA include fracture, nerve damage and weakening of the triceps tendon.
TEA is performed under general anaesthesia, often with a local anaesthetic also injected into the joint to numb the region. The procedure takes about 2 hours and following the operation you will usually be required to stay overnight. Rehabilitation guidance will be provided to patients, along with a wrist splint to keep the joint stable during the recovery period.
Introduction
What is Total Elbow Arthroplasty?
This procedure, also known as Total Elbow Replacement, involves replacing the damaged joint surfaces of the elbow with a prosthetic joint. Total Elbow Arthroplasty (TEA) is performed on the humerus and Ulnar joint surfaces (articulating surfaces) of the elbow.
The elbow is a hinge joint which is due to its movement resembling that of a door hinge. It is composed of the humerus bone (upper arm), the ulna and the radius (forearm bones). The meeting point of these three bones is the elbow joint, and the surfaces of the joining surfaces of the bones are layered with cartilage. The purpose of these cartilages is to protect the bone and enable smooth movement and functioning of the joint. A smooth tissue known as the synovial membrane covers the remaining surfaces of the elbow joint and is responsible for the production of synovial fluid which helps to maintain and lubricate the joint.
The artificial elbow joint consists of a metal and plastic hinge connected to two stems. These stems fit into the hollow canals of the ulna and humerus bone.
Why is TEA performed
Pain is the primary indication for TEA. For patients suffering from Rheumatoid Arthritis, the pain relief resulting from TEA is excellent in the majority of patients. Rheumatoid arthritis is categorised as an ‘inflammatory arthritis’. It is characterised by the inflammation of the synovial membrane, called synovitis, which eventually can damage the cartilage and underlying bone. The symptoms of this condition include pain which is worse in the morning and after long periods of inactivity, as well as stiffness.
Painful Osteoarthritis is another indication for TEA. The condition is classically referred to as an ‘age-related disease’, as it usually occurs in people over the age of 50. It may also occur in the young though, especially in people who are highly active, thereby putting a lot of stress on their joints. In Osteoarthritis, the cartilage is worn away which exposes the underlying bones that then rub against each other. As a consequence, the joint becomes stiff and painful. TEA replaces the damaged cartilage with a prosthetic joint that prevents the mechanical damage of Osteoarthritis.
Traumatic arthritis is another possible indication for TEA. It occurs following serious injury to the elbow, which may result in fractured bones of the elbow joint, ligament or tendon damage. Over time, this can lead to damage to the joint cartilage, resulting in pain and limited elbow function.
Severe fractures are a common indication for TEA. It is particularly useful when the blood supply to the shattered pieces of bone in the elbow joint is interrupted, thereby preventing the healing process. Older patients suffering from osteoporosis, a condition which makes the bones more fragile and prone to breaking, are more likely to fracture their elbows.
The TEA Procedure
Anaesthesia
TEA is performed under general anaesthetic, which will mean that you will be asleep during the surgery and so will not feel any pain. You may also receive a local anaesthetic injection in the elbow joint to be operated on, which will numb the region both during and for some hours after the operation.
Pain Control
You may be prescribed local anaesthetic, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and if the pain is severe, opioids can also be prescribed, such as codeine. There is a tendency to avoid opioids due to the dependence patients can develop on them. It is important to stop taking opioids as soon as your pain levels are under control.
Will I need to prepare for the surgery?
You will be booked in for a pre surgery assessment which will allow the medical team to make the necessary preparations for your operation. Your medication will be reviewed, as you may be required to stop some of them. Blood thinners, ibuprofen and most arthritis drugs are usually stopped prior to TEA.
It’s also essential to make preparations at home for your recovery and transport after the surgery. Placing your belongings and cooking utensils on lower shelves are some easy changes you can make to your home which make everyday activities easier during the recovery period. You will need some help at home with everyday activities, which you can discuss with the doctor during your appointment.
TEA is usually completed in two hours and you will be required to stay in the hospital overnight. It is important to inform family and friends of this, so that the arrangements for bringing you home are made in advance.
Steps of the surgery
You will be positioned in the lateral decubitus position as shown in the image below. Your arm will be covered in a drape, with the elbow exposed to be operated on.
- Markings will be made to identify the major landmarks of the elbow, the ulnar nerve and the incision site. An incision is made down the back of the elbow which is 15 cm in length.
- The superficial layer of tissue is then separated from the deeper muscular layer on the inner side of the elbow. The ulnar nerve is then moved out of the way to prevent damage during the procedure. The superficial layer of tissue on the outer side of the elbow is also separated from the underlying muscle, such that two flaps are created.
- The deep layer approach involves manipulating the triceps muscle tendon to lift it off the bony surfaces of the elbow for better exposure. Your surgeon may also create a small split in the triceps tendon, which does not affect the muscle integrity.
- Preparing the bony surfaces for the replacement joint involves ‘shearing’ the humerus and ulnar components of the elbow joints and preparing the medullary canal of each bone for prosthesis insertion.
- The prosthesis is then inserted using cement to fix them in the proper depth of the humeral and ulnar shafts. Proper washing of the shafts and adequate plugging with cement will ensure good fixation of the prosthesis.
- Once the prosthesis is inserted saline solution will be used to thoroughly wash the elbow joint, removing any debris. Refixation of any ligaments or triceps tendon at this stage would be necessary to ensure muscle function and elbow joint stability. The wound is then closed up using sutures, and sometimes a drain is left in, although this is usually reserved for patients that have lost a lot of blood during the surgery (4).
Post-operative care and follow up
Your operated elbow will be dressed and wrapped with a padded bandage. The bandage often includes plaster to keep the elbow out straight and to protect it during the healing process. It is important that you keep the dressing dry and clean, whilst ensuring the arm is elevated using a sling, and while resting you can use pillows. This will help to reduce swelling.
You will be instructed to begin moving your finger and wrist joints according to the exercise instructions you will be provided with. It is essential to begin doing these immediately to avoid developing stiffness in these joints.
You will be given painkillers which you should begin taking before the local anaesthetic wears off so as to avoid experiencing pain. Over the counter medications such as paracetamol and ibuprofen should be sufficient, but in the situation where pain still persists…
Once your pain levels are under control and the X-ray review is satisfactory, you will be discharged home.
You will be booked in to visit the clinic within the first two weeks of recovery. During this appointment, your wound will be assessed to see how it is healing, and the stitches and plaster will be removed. It is important you continue to perform the exercises shown in your rehabilitation sheet, whilst avoiding carrying anything heavier than a cup of tea with the recovering arm’s hand.
You will continue to visit clinics for reviews for up to one year post surgery. Your strength and range of motion may continue to improve for this full length of time, so once again it is essential you continue performing your rehabilitation exercises regularly. It usually takes about 6 weeks before you are able to resume driving, but of course it is important to check whether you feel comfortable driving without putting yourself or others at risk.
Resources
https://www.ouh.nhs.uk/shoulderandelbow/information/documents/A5ElbowReplacementAppendix8.pdf
Authors
Liam Oktay
Conflicts of interests
None to declare