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Surgical Options for Arthritic Elbows
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Posted on: 07/30/2008
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Surgical treatment for elbows affected by arthritis differs between patients because of the type of arthritis, how severe it is, and how old the patient is. The authors of this article reviewed the different types of surgery available for treatment of arthritic elbows.
The elbow, unlike other joints, is more prone to being stiff when it is damaged, like with arthritis, making treatment to return use and motion a priority. Also, unlike arthritis in the hip, knee or shoulders, the elbow doesn't usually deteriorate from primary osteoarthritis. The elbow usually deteriorates from rheumatoid arthritis, trauma (injury), or other types of arthritis. Patients with deterioration in the elbow from osteoarthritis tend to fall into certain categories, such as heavy-machine operators, weight lifters, and professional overhead athletes - people who regularly put a lot of force on their elbows.
When evaluating the elbow, the patient will complain of pain and inability to fully extend the elbow (the range of motion). After a while, the pain becomes more frequent and occurs whenever the elbow is bent or straightened out. At this point, the surgeon must take into account the patient's job and what the effects of surgery will have before deciding on what type of surgery to perform. The examples used in the article are that of a baseball pitcher and a jackhammer operator. If the athlete has surgery to remove the bony growth that has formed on his or her elbow, this could cause the elbow to become unstable and cause further damage. On the other hand, if a jackhammer operator was to have an elbow replacement, the vibration from the jackhammer could destabilize the new joint and cause loosening.
Another issue to be considered is the health of the arm above and below the elbow. Is the bone strong enough to tolerate a replacement, is there enough healthy soft tissue, where is the nerve located, and has there already been surgery are just a few of the questions that need to be asked.
If the patient has rheumatoid arthritis, only about 5 percent of patients end up with an elbow problem alone that needs to be fixed with surgery. Most often, the shoulder and wrist are affected as well. Therefore, any treatment done to the elbow has to take into consideration how it will affect the wrist and shoulder.
When examining a patient, the surgeon should evaluate the patient completely with particular attention on not just the elbow, but joints nearby. The patient should be questioned about previous treatments, including medications and splinting. The condition of the patient's skin around the elbow is important to know to see if it would heal well following elbow surgery. The range of motion should be checked and the strength of being able to bend at the elbow.
X-rays can show if there has been narrowing in the joint and if there are any bony growths. If necessary, the surgeon can get a computed tomography image (CT scan) and/or magnetic resonance imaging (MRI) to see more clearly around the elbow. If there is a question with the nerves in the elbow, further testing can also be done. If the surgeon has any reason to suspect an infection, blood tests and even withdrawing some fluid from the elbow for testing can be ordered.
Once it's been decided that surgery is needed, the surgeon has to decide what approach. The least invasive is the arthroscopic debridement, which is done for mild to moderate cases of arthritis that haven't responded to non-surgical treatment. Arthroscopic surgery needs just a few tiny incisions for the instruments and a camera to enter the elbow. For patients with rheumatoid arthritis, the surgery is done to remove inflamed tissue that is causing pain and destruction in the joint. For people with osteoarthritis, the procedure is done to remove bony bits or loose pieces of tissue or bone that are affecting elbow movement.
The results of arthroscopic debridement show 85 to 90 percent success for short-term improvement in pain and function, but there long-term results are not well known and some studies show only about 50 percent improvement. Complications from the procedure can include injury within the joint caused by the instruments.
Another procedure, ulnohumeral arthroplasty, or a partial bone replacement, is another option that can be done in several different ways depending on surgeon preference and the reason for the surgery. This surgery is usually done for patients who have extreme pain and inability to move their elbow from mild to moderate arthritis. It is usually only done with patients who have osteoarthritis as it would not be beneficial for patients with rheumatoid arthritis or other types of arthritis.
The results of the surgery show that it is fairly successful if used in patients with mild to moderate joint degeneration, at about 75 percent success rate. This drops over time and to approximately 50 percent after around 12 years following surgery. Complications include further degeneration and some nerve injury.
The oldest procedure done on the elbow is the interpositional arthroplasty, which is another type of replacement or insertion of a graft. This procedure is done for patients who have advanced arthritis but are considered to be too young for a total elbow replacement. The deciding factors for this surgery is that the patient have incapacitating pain, considerable loss of elbow range of motion, and/or be younger than 30 years old if the surgery is for rheumatoid arthritis and younger than 60 years old if the surgery is for another type of arthritis.
Even if a patient meets the requirements, there are some issues that would cause the surgeon not to choose this procedure. They include if there was a history of infection in the elbow, if the bone around the elbow is not strong enough, if the patient is a heavy laborer, or if the patient has an unstable elbow.
The results of this surgery are generally good with a success rate at 5 years of at least 70 percent. There are, however, high rates of complications, regardless of the surgeon's experience. There was a reported rate of 27 percent of complications in one small study of 27 patients. Complications are many but include problems with the pin site, deep infections, and surgery failure.
The total elbow arthroplasty, or full replacement, is done for patients who have moderate to severe arthritis, causing pain, limited range of motion, and is affecting function. The type of arthritis and the effect it has had will be the deciding factor as to which of three different types of arthroplasty is used. There are some types of patients who surgeons must weight the pros and cons before attempting this surgery. These include patients who have had infections in the elbow, if there are multiple scars around the elbow, if patients may not be motivated to follow up with proper rehabilitation, or those who may not be able to live within the limitations of the replacement, such as not being able to lift more than 10 pounds or lifting 2 pounds repetitively. These issues are important to consider to reduce the chance of complications or replacement failure.
In assessing the effectiveness of the total elbow arthroplasty, researchers found an average of 50 percent success after 10 to 14 years after surgery. This drops, however, to 25 percent after 15 to 19 years, and longer. Complications include infection, which happen in about 2 to 11 percent of cases. The next most common complication is loosening of the implant.
The authors concluded that the choice of procedures to improve the function and reduce pain in the elbow depends on many pre-operative issues, functional requirements of the elbow for each patient, as well as how well the patient is expected to cooperate in terms of rehabilitation and respecting limitations of the repaired elbow.
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References:
Robert A. Gallow, MD, Alexander Payatakes, MD, and Dean G. Sotereanos, MD. Surgical Options for the Arthritic Elbow. In Journal of Hand Surgery. June 2008. Vol. 33. No. 5. Pp. 747-759
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