Introduction
The elbow is an intricate hinge joint that mainly comprises three bones, namely: the humerus (upper arm bone), the ulna bone (one of the two bones of the forearm), and the radial bone (forearm bone present on the lateral side of the forearm). The elbow joint connects all three bones. The elbow joint contains synovial fluid to lubricate and prevent friction during various arm movements. This joint is also covered by a smooth tissue called cartilage. Damage to any of these parts may result in chronic pain, swelling, and stiffness of the elbow joint, requiring elbow replacement surgery. This article will discuss total elbow replacement surgery, its indications, procedure, and contraindications.
What Is Total Elbow Replacement Surgery?
Total elbow replacement surgery is otherwise referred to as total elbow arthroplasty. It is a relatively infrequent orthopedic surgery that involves replacing damaged parts of the elbow joint with a prosthesis. This surgical procedure is less commonly performed when compared to hip and knee replacement surgeries. They are usually performed on patients who have failed to respond to conservative management options for a long time. They are more commonly prescribed for patients with mild to moderate joint osteoarthritis (a degenerative joint disease). Like any other surgical procedure, it has its pitfalls and challenges.
What Are the Indications?
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Chronic pain in the elbow that failed to improve with conservative management options.
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When there is a traumatic fracture that results in fractures of the intra-articular distal humerus bone that are un-reconstructable for orthopedic surgeons.
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In patients with post-traumatic arthritis (the type of arthritis that occurs after severe trauma to the elbow joint).
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Rheumatoid arthritis (a chronic inflammatory condition affecting the synovial membrane of the joints).
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Tumors of the elbow joint require surgical reconstruction.
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In patients with chronic instability due to damage to the ligaments of the elbow joint or elbow dislocation.
What Are the Contraindications?
Total elbow replacement surgery is generally contraindicated in the following conditions.
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Local or systemic infections.
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Degenerative muscle diseases (poor functioning of the muscles surrounding the elbow joint)
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Neuropathic arthropathy of the elbow joint (a joint disease secondary to sensation loss)
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Incapability to perform post-surgical rehabilitation.
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In patients with higher physical demands or patients less than the age of 50 years. Studies show an increased prognosis rate after the procedure in patients with lesser physical demands and the elderly.
What Happens Before the Surgery?
The orthopedic surgeons will explain the procedure and its details and obtain consent. The surgeon will perform detailed and thorough physical examinations of the patient before the surgery. Patients with chronic conditions like heart disease are advised to get an opinion from their cardiologist. The doctor will evaluate the drug history of the patients. Patients taking blood thinners or anti-coagulants will be advised to stop these medications before the surgery after getting an opinion from the cardiologist. The surgeon will assess the patient's vitals before the surgery.
How Is Total Elbow Replacement Surgery Performed?
The planned patient-specific instrumentation may be performed for the pre-operative planning of the procedure regarding the type of prosthetic implants to be used and the surgical approach. The type of implant selected is based on the joint's stability and extension.
There are two types of prosthetic implants, namely:
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Linked Implants: Otherwise known as semi-constrained design implants, these involve the placement of a hinge that physically connects the components of the implants. This type of implant is commonly used since it provides more stability and prevents dislocation.
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Unlinked Implants: Otherwise known as unconstrained implants. This type of implant has no physical connection between the components and is usually preferred for patients with well-preserved bone stock.
Total elbow replacement surgery is generally performed under general anesthesia. During the procedure, the patient is positioned supine or lateral decubitus (in which the person lies on their side with the operative side up).
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The surgeon will make a surgical cut in the posterior aspect of the elbow joint.
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After preparing the incision, the surgeon will decompress the ulnar nerve and mobilize the triceps muscle to view the ulna, humerus, and radial bone.
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At the same time, the surgeon will take care to secure the ulnar nerve.
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The fractured segments, bone spurs, and scar tissues are removed, and the surgeon will prepare the humerus and ulna based on the guidelines for placement of the prosthetic implants.
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The surgeon will insert a guide pin in the medullary canal (innermost part of the bone) to determine the bone's axis and the prosthesis's proper placement.
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Improper alignment can compromise the quality of the prosthesis and result in excessive wear and tear.
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All the trial components of the joints are placed, and the joints are reduced to assess the stability of the elbow joint.
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The trial components are then removed, and the definitive components are assembled.
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While maintaining the depth and rotation of the implant components, the implant components are cemented at once or separately.
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Once the definitive components are assembled in position, the elbow joint is thoroughly washed with the saline solution to remove any debris.
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To secure the muscles, the mobilized and released tricep muscle flap is refixed with Vicryl sutures (a synthetic absorbable suture material). Finally, the surgeon will perform surgical closure of the elbow.
What Happens After the Surgery?
The healthcare provider will prescribe antibiotics postoperatively to prevent infection. The doctor will also prescribe a combination of other medications for pain relief. Like any other surgical procedure, the surgeon will refer the patient to physical therapy for rehabilitation to improve the patient's functional outcomes. The therapist will tailor an individualized rehabilitation program for the patient.
Conclusion
Total elbow replacement surgery is a surgical procedure usually performed in patients with elbow pathologies. Even though it is rarely performed, it is one of the preferred surgical procedures for patients with rheumatoid arthritis and has favorable surgical outcomes. The post-operative complications of the procedure still pose a challenge for orthopedic surgeons. However, various research and studies have been conducted to explore and improve implant designs and surgical techniques.
