Elbow Surgery Options
The right surgery may help this hard-to-treat joint. Learn the pros and cons to each type.
Elbow surgery can be challenging, not only because the elbow is a relatively small and complex hinge joint, but also because next-generation arthritis drugs have created healthier patients who need longer lasting, more durable treatments, including implants.
Connected by three long bones – the humerus in the upper arm and the ulna and radius in the forearm – the elbow positions the hand properly in space, so a pain-free, stable elbow is essential for most daily activities. Surgical options are only considered when medications and other measures don't relieve severe pain and loss of motion. Here are insights into the most common types of elbow surgeries.
This procedure removes the synovium – the soft membrane lining the joint. In a healthy elbow, the synovium produces a lubricating fluid that eliminates friction as the arm moves. But in rheumatoid arthritis (RA) and other forms of inflammatory arthritis, the synovium becomes inflamed, eventually eroding cartilage and causing pain and swelling. Removing the synovium temporarily stops this destructive process. Synovectomy can be performed arthroscopically, using small incisions and fiberoptic (camera) technology, or as a conventional open procedure. Recovery time depends on whether the procedure was performed arthroscopically or conventionally, and on the amount of tissue damage. Rehabilitation takes a minimum of two months.
Best candidates are patients in the early stages of inflammatory types of arthritis (like RA) with little or no cartilage damage.
Pros – Synovectomy can improve symptoms significantly, says Robert N. Hotchkiss, MD, director of research in the hand and upper extremity service at Hospital for Special Surgery in New York City. "Performance and pain scores improve, swelling goes down and many [patients] return to near-normal function." Arthroscopic synovectomy usually results in a faster, less painful recovery.
Cons – Synovectomy doesn't stop disease progression. After several years, the synovium starts to regrow and symptoms usually return. (The surgery can be repeated). In addition, nerve injury is a significant risk in arthroscopic elbow procedures because the tight space is difficult to navigate and major nerves are close to the joint.
This technique removes bony growths in the joint along with any loose bits of bone or cartilage. In some cases, the upper end or head of the radius is also removed. Although no longer recommended for knee osteoarthritis (OA), debridement is successfully used for posttraumatic and primary OA in the elbow. Like synovectomy, it can be performed arthroscopically or as an open procedure. Recovery time – between 12 and 24 weeks (including rehabilitation) – depends on whether the procedure was performed arthroscopically or conventionally, the age of the patient and what was done (for example, if the head of the radius is removed, the recovery period will be longer).
Best candidates are patients with mild to moderate OA who have stiffness and minor pain. Those with pain throughout their full range of motion or advanced disease are not good candidates, according to Robert Wysocki, MD, a hand, wrist and elbow surgeon and assistant professor at Rush University Medical Center in Chicago.
Pros – Most people experience 80 to 95 percent pain relief and increased range of motion after the procedure. Open and arthroscopic procedures have equally successful outcomes, but arthroscopic techniques, which have improved considerably in the past decade, are associated with faster healing and less pain.
Cons – Boney growths tend to recur and range of motion decreases over time, although many people continue to experience significant pain relief. Like arthroscopic synovectomy, arthroscopic debridement "carries a risk of nerve injury for even the highly trained elbow arthroscopist," Dr. Wysocki says.
Elbow interpositional arthroplasty
The goal of interposition arthroplasty is to relieve pain that occurs when bone surfaces rub together. To accomplish this, the ends of the bones are reshaped, and a small section of the patient's Achilles tendon or other soft tissue is fitted into the space between the joint surfaces. "It's like putting new tread on a tire," Dr. Hotchkiss says. Recovery time, including healing and rehabilitation can be up to four months.
Best candidates are cctive people with primary OA, posttraumatic OA or inflammatory arthritis who have too much damage for debridement but are too young for elbow joint replacement. "We might consider this surgery in a younger, relatively high-demand patient, such as a school teacher who can no longer write on the blackboard," Dr. Hotchkiss says, adding that candidates for the procedure also must have a stable elbow (with ligaments that aren’t too loose to hold the bones in place) with minimal bone loss.
Pros – Interposition arthroplasty can relieve severe pain while retaining some elbow function, and unlike an artificial joint, transplanted tissue won't loosen or dislocate. Bone stock is also preserved, which is crucial if elbow replacement is needed in the future. In Dr. Hotchkiss' experience, however, the results of the procedure have been long-lived: "We've done 20 or so [interposition arthroplasties] over Larsen class 3 [a 0 to 5 scale that grades disease severity] and none has had to go to total elbow replacement 15 years out."
Cons – The procedure doesn't completely relieve pain or restore full function and can’t be performed on some patients with severe disease.
Total elbow arthroplasty
Similar to hip or knee replacement, this surgery replaces damaged parts of the elbow with artificial components. Elbow implants may be linked, unlinked or linkable. A linked implant consists of two metal stems – one in the humerus and one in the ulna – joined by a cobalt-chrome hinge pin that articulates with the joint. In an unlinked prosthesis, the humeral and ulnar components aren't mechanically joined, relying instead on the surrounding tissue for joint stability. Newer linkable implants give the surgeon the option of leaving the implant linked or unlinked, depending on what's found during surgery. Average recovery time is a minimum of 12 weeks.
Best candidates were originally older, less active adults with end-stage inflammatory arthritis. However, elbow implants are now also used for OA and posttraumatic OA. Because they generally don't last more than a few years, they are not recommended for people less than age 60.
Pros – Elbow replacement can successfully relieve pain and restore lost motion and function in people with severely damaged and deformed joints.
Cons – The complication rate for elbow replacement is higher than for any other joint. Linked implants can ensure a stable elbow, even with severe bone loss, but tend to loosen and wear out quickly. Unlinked implants dislocate easily and for that reason are used less often. High overall failure rates – 25 percent fail at five to seven years – are due in part to poor tissue quality in the joint and, paradoxically, to the effects of better arthritis drugs.
"With the advent of DMARDs and biologics, we are presented with a new patient," Dr. Hotchkiss explains. "They are living longer, are more active and the adjacent joints are healthier. The elbow is just as arthritic and painful, but the wrist and shoulder are nearly normal, which means implants have to last much longer and are subjected to greater loads and strains."
Furthermore, there are few options when implants fail. "The ulna is a notoriously thin, narrow bone with a small diameter, so when an implant becomes loose, bone deficiency is a real problem. You can go from having an arm that can do light things quite well to one with no function at all," Dr. Hotchkiss says. "To be skeptical about elbow arthroplasty is a helpful and useful position."