Total elbow replacement

Total elbow arthroplasty
Summary

This operation is performed for arthritis affecting the elbow.  This can be caused by conditions such as rheumatoid arthritis, osteoarthritis or as a result of trauma.  Increasing pain and stiffness occurs as the joint surfaces get damaged.  With worsening arthritis, the pain can get so bad that it interferes with your life.  Pain killers may not help anymore and you struggle to do simple activities such as getting your hand to your mouth.  A total elbow replacement is a good operation to reduce pain and improve movement caused by elbow arthritis.

Factors to Consider

You have been diagnosed with elbow arthritis.  It is likely that you have already tried non-surgical treatments for your elbow such as pain killers, lifestyle changes, physiotherapy and injections.  Keyhole or open surgery may well have also been tried to clear the joint of debris.

If these measures have not improved your symptoms then the next logical step is to consider an elbow replacement.

This is a major procedure with potential risks and so you need to consider this carefully.  When considering any operation it is important for you to weigh up how bad your symptoms are and what an operation can achieve.  An elbow replacement is effective at improving pain.  It is also quite effective at improving mobility and function.  It does, however, need to be protected and your surgeon usually will place a weight limit of approximately 5kg on your arm following surgery.  It should therefore be kept as a last resort.

If your pain from your elbow is only at the extremes of movement then keyhole or open surgery to clean out the joint should be tried first.  If your pain, however, is throughout all movements then the only option is a total elbow replacement. 

Description of Surgery

Description of surgery 

A total elbow replacement removes the worn out joint and replaces it with an artificial joint that recreates the shape of a healthy elbow.  The joint is formed using a metal and plastic hinge and cement is used to secure it into the arm and forearm bones.

The operation is performed under a general anaesthetic through an incision along the back of the elbow.  The ulnar nerve is first identified and moved away from the operative field.  The old joint is then cut out and a new one prepared and cemented in place.  The operation itself takes approximately 2 hours but you will spend 3-4 hours in the operating department.  

Anaesthetic

The operation is usually performed under a general anaesthetic and so you will be given instructions as to when you need to stop eating and drinking (normally the night before) before you come into hospital.  

It is common for you to be offered a nerve block to help with the pain.  The nerve block allows excellent pain relief immediately after the operation.  It is considered a safe method of providing pain relief with few complications (less than 1%).  You will wake up with a numb arm, similar to when you sleep on your arm awkwardly.  The block wears off within 12-24 hours and so it is important to take pain killers the night after the surgery even if you don’t have pain when you go to sleep.

The anaesthetist will talk more about the nerve block when they see you.  If you do not want a nerve block your pain can be well controlled with local anaesthetic given during the operation.

What are the risks?

All operations involve an element of risk.  Joint replacement surgery is a major operation and so, as with any major operation, complications can occur.  

The risk of infection is small and is thought to be about 2%.  This is a serious complication but is thankfully quite rare.  You are given antibiotics around the time of your surgery to reduce your risk.  

If infection does occur you may need to have the elbow replacement removed, treat the infection using antibiotics and then replace the elbow at a later date.

Damage to nerves and blood vessels around the elbow can occur but this is rare.  Total elbow replacement carries a risk of developing blood clots in the leg veins (DVTs) and your lungs (PEs) of approximately 0.5%.  You will undergo an assessment to work out your risk for developing blood clots before your surgery and your doctor may prescribe blood thinning medication depending on this assessment.

All joint replacements can wear out, loosen or dislocate.  Most elbow replacements (>80%) continue to work well beyond 10 years.  

After Surgery

Pain

Local anaesthetic or a nerve block will be used during the operation and so you will feel comfortable when you first wake up.  The nerve block can make your whole arm feel numb.  This can last up to 12 hours but the shoulder may be sore after it wears off.  You will be given a combination of pain killers to go home with.  It is important that you take regular pain relief so that you can start moving your arm early.  

Sling

You will wake up with your arm in a sling.  The arm should be comfortable but it is important to let the nurses know if you have pain so that further pain killers can be given.  You will need to use this sling during the first 2 weeks and so it is important to understand how it works.  The nurses and physiotherapists will help you with this.

Wound care

The wound is closed using dissolvable stitches.  There will be dressings applied to the wound following your operation.  These can occasionally come off and will need to be replaced during the first 2 weeks after surgery to protect the wound.  

The dressings are splash proof but not waterproof and so you should avoid getting them wet.

The stitches do not need to be removed but there may be loops at each end of the wound that can be trimmed.  The nurses will arrange this to be done at your local GP practice before you are discharged.

Physiotherapy

The physiotherapist should see you before the operation to explain some simple exercises you can do after the operation.  They will also ensure a physiotherapy appointment is made for you within 3 weeks of the operation.  Physiotherapy can be arranged local to you.  

Driving

You can drive when you feel you are safe to drive.  This means that you feel confident that you have full control of your car and are able to swerve out of the way of something in the road.  This will vary between patients but normally takes about 6 weeks.  

Return to work

This depends on what your job is.  You should be able to return to a “desk job” at 6 weeks.  If you have a more manual job your surgeon will likely recommend that you change this to be more sedentary in order to protect the elbow.  Please discuss this further with your surgeon or physiotherapist if you feel unsure.  A sick note can be given to you at the time of your surgery if required.  Please ask the nurses on the ward if you need one.

What to expect

Recovery following surgery can be quite variable.  Most people will feel good pain relief at an early stage with an improvement in movement taking longer.  Your symptoms should be improved/improving by 3 months with the majority fully recovered by 6 months.  It can, however, take up to a year for some patients to fully improve.