Surgery for painful elbow joint arthritis, elbow instability, and tendonitis: Elbow replacement, ligament reconstruction and repair, and tendon surgery
Edited By: Thomas Trumble, M.D.
Last updated Friday, September 08, 2006
Figure 1 - In this anatomic specimen, the lateral collateral ligament (LCL) avulsion has been simulated and the ligament that has been disrupted and torn off the distal humerus is held in the forceps. One can now look directly into the elbow joint. Figure 2 - The tendon graft is held in a clamp and one loop of the graft has been woven through the ulna and now will be attached to the humerus to reconstruct the ligament. Figure 3 - Anterior posterior (AP) x-ray of a patient with rheumatoid arthritis.
Figure 4 - This is a lateral x-ray of a patient with rheumatoid arthritis.
Figure 5 - This is an APX of a patient with the implants in place for a total elbow replacement.
Figure 6 - This is an intra-operative photograph showing that the ulna nerve on the yellow vessel loop has been protected with the components in place looking at the back or posterior side of the elbow.
Figure 7 - Physical exam with trial components look like that are inserted prior to submitting the final component.
Figure 8 - This diagram of the lateral aspect of the elbow demonstrates the narrow attachment of the (ECRB). The surgeon needs to exam the patient to ascertain the diagnosis and determine if additional tests are necessary. Frequently, these can be treated by activity modification and bracing.
Figure 9 - This demonstrates a strap worn with a small cushion to apply pressure of the lateral side of the elbow. If conservative treatment with therapy is not effective, then surgery to detach and reattach the muscle at a region where it is under less tension can be highly effective. Figure 10 - In this figure, an incision is made on the lateral side of the lateral aspect of the elbow so that the ECRB can be detached from the lateral epicondyle where it is demonstrated degeneration and tearing and reinserted slightly distally so that it attaches in the forearm instead of at the elbow.
Figure 11 - This figure demonstrates the regular and misshapen end of the radius following a fracture where the radial head was removed. The patient developed chronic pain and instability.
Figure 12 - Replacement of the radial head helps restore the length and provide elbow stability and relieves pain.
Figure 13 - This demonstrates the implant that this available as a device that can be distracted provide custom increase in length to suit the patient’s biomechanical needs to stabilize the forearm.
Figure 14 - This radiograph demonstrates the anterior posterior AP view following surgery.
Figure 15 - The device is demonstrated prior to wound closure after being implanted in the patient.
SummaryOverview This article reviews common painful conditions that affect the elbow joint, including elbow arthritis, instability, and tendonitis (tendinitis), and discusses several surgical procedures that can help relieve pain and restore function, such as total elbow replacement (arthroplasty), ligament repair and reconstruction, and tendon surgery.
The elbow is a critical joint for hand and upper extremity function. Three main problems that affect the elbow are:
1) Instability injuries due to ligament disruption
2) Arthritis
3) Tendonitis, commonly referred to as tennis elbow and golfer’s elbow, or lateral and medial epicondylitis, respectively
Instability injuries: These can occur in athletes such as patients with repetitive throwing or in individuals who have had a sudden fall. Key ligaments involved are the lateral collateral ligament and the medial collateral ligament, which act as hinge ligaments to maintain the stability of the elbow. The key elements to these reconstructive procedures are to restore the correct biomechanical function of the ligaments as seen in tendon grafts that are secured to the bone. The alignment of the ligament reconstruction is critical and a number of nerves are in close proximity to these ligaments. Therefore these cases require team experience dealing with elbow injuries. Rehabilitation is a key phase in the treatment of elbow problems.
Arthritis
Arthritis of the elbow can develop from repetitive trauma or severe forms of systemic arthritis such as rheumatoid arthritis. Once the clinical examination demonstrates pain and a limited range of motion, and x-rays confirm degeneration of the joint, part of or the entire elbow can be replaced. Patients benefit most from this surgery if they are well motivated and in good health.
Tendonitis
This typically occurs in the lateral or medial prominences that are known as the lateral and medial epicondyles. In this region, the muscles attach to a narrow segment of bone and repetitive stress can result in tearing and degeneration where the muscle attaches. For example, one muscle on the lateral side of the elbow, the extensor carpi radialis brevis (ECRB) attaches on a very narrow segment of the lateral epicondyle, and so is susceptible to this condition.
Characteristics of elbow instability, arthritis, and tendonitis Elbow instability presents as giving way or instability, or as pain with
activity such as throwing activities. In trauma, the patient presents with an
acute dislocation that needs to be addressed with an accurate reconstruction.
Arthritis presents with pain and stiffness that gradually increases over
time.
Tendonitis presents with a reoccurring pain over the lateral
(outer) or medial (inner) aspect of the elbow. It is particularly worse with
lifting activities for the lateral elbow and pushing activities with the medial
elbow.
Types Elbow instability
Instability can affect either the lateral (outer) or medial
(inner) aspect of the elbow. In some cases, the patient will present after an
acute injury with the elbow completely dislocated, and then instability reoccurs
when proper reconstruction is not performed. Athletes frequently develop medial
elbow instability and patients with trauma or prior surgery often develop
lateral elbow instability.
Arthritis
These patients present with
either traumatic arthritis when they have had prior injuries such as the
dislocation described above or with instability or fractures. These patients
often have no problems with their other joints. Rheumatoid arthritis patients
present with serious arthritis involving a number of joints. They are often on
powerful systemic medications.
Tendonitis
Tendonitis can be broken
down into a group of patients with lateral epicondylitis, (the most common form
- also known as tennis elbow with pain in the lateral aspect of the elbow), and
medial epicondylitis (golfer¹s elbow), a condition which frequently present with
pain in the medial side of the elbow and pain with certain types of lifting or
pushing activities.
Similar conditions The most difficult aspect in the diagnosis of elbow instability, arthritis, and
tendonitis is that they can often be confused. It is important for the patient
to have a thorough examination, radiographs, and often-additional studies such
as magnetic resonance imaging (MRI) with or without arthrograms.Incidence and risk factors Elbow instability
Instability is common in active individuals, particularly
in individuals involved with sports, such as throwing sports, or contact
sports.
Arthritis
Elbow arthritis is less common, but when it occurs
it has severe impact on the patient’s activities because it prevents the patient
from placing their hand in space, even for simple activities. Traumatic
arthritis is more common than rheumatoid arthritis.
Tendonitis
This is
an extremely common condition. Lateral epicondylitis is more common than medial
epicondylitis and occurs frequently in people over forty years who participate
inrepetitive activities and sports.
Diagnosis Elbow instability
This is best diagnosed with a thorough examination, x-rays,
and then magnetic resonance imaging enhanced with an arthrogram. The arthrogram
involves injecting the elbow with a small amount of dye that helps to add to the
clarity of the MRI images. These images can help to demonstrate ligament
disruption.
Arthritis
Plane x-rays are frequently the best screening
tool to help diagnosis arthritis. Occasionally, arthrograms coupled with
computerized tomography provides an improved definition of the bone surface to
detect which area of the arthritis is more critical and causing the symptoms.
Arthrography, also involving the injection of a dye, helps to demonstrate if
there are loose bodies or small bone chips floating in the joint that can cause
locking and pain.
Tendonitis
Clinical examination is still the best
examination for this condition, along with plane x-rays to help rule out the
possibility of arthritis co-existing with the tendonitis. Magnetic resonance
imaging can help determine the severity and whether the patient will respond to
conservative treatment or will require surgery.
Medications Elbow instability
Medications are not highly effective because these patients have a mechanical problem that needs to be addressed surgically.
Arthritis
Medications can be extremely helpful especially non-steroidal anti-inflammatory medications. Occasionally, food supplements such Glucosamine have been reported to provide relief.
Tendonitis
Anti-inflammatory medications can be very helpful in the initial phase of treatment, but are less helpful in the chronic phases. Again, this is usually non-steroidal medication such as Ibuprofen or Naproxen. The patients are advised to follow the manufacturer’s recommendation when taking these medications. For each medication, the patient should learn the risk and possible interaction of other drugs, the recommended dosage, cost, and adverse effects.
Exercises Elbow instability
Exercise will not help this condition as it truly involves
a biomechanical instability that has to be addressed with a surgical
reconstruction.
Arthritis
Gentle stretching exercises can be helpful
for arthritis, but multiple repetitions can actually aggravate the condition by
putting further stress on the joint. The patient should consult with their
doctor and therapist before embarking on a regular exercise
program.
Tendonitis
Tendonitis can respond to modification, which
means changing the patient’s lifting pattern, more than exercises. It is
important in lateral epicondylitis to make sure to lift objects with the palm
up, which places the stress on the opposite side of the elbow. The opposite is
true for medial epicondylitis where it is important to lift with the palm down
to place the stress away from the medial side of the elbow.
Possible benefits of treatment for elbow instability, and tendonitis Elbow instability
The key aspect of this surgery is to reconstruct the
biomechanics of the joint to repair and replace the ligaments. This provides
stability to relieve symptoms and prevent long-term arthritis.
Arthritis
A joint replacement surgery, either to replace a part of
the joint, such as the radial head or the entire joint with total elbow
prostheses can help to relieve pain and improve motion. In young patients with
an active lifestyle, the goal is to make sure that all possible conservative
options have been used so that the devise is not implanted at too young an age
in a patient which can lead to loosening.
Tendonitis
The
decompression surgery that is performed can be very effective in patients who
have exhausted conservative treatment. Chronic tearing of the muscle attachment
produces pain and is relieved with a debridment and removal of the inflamed
tissue and reattaching the muscle slightly closer to the forearm.
Types of surgery recommended Elbow instability
Ligament reconstruction is recommended and the type of
reconstruction is designed to replace the anatomy and function of the ligaments
either on the medial or lateral aspect of the elbow. This can be done with
either autologous tendon grafts (from the patient’s own arm or leg) or
allograft tendon grafts from human donors. The autologous grafts may have less
chance of tissue reaction and may be incorporated faster, while the allografts
minimize the donor site deficit. In most cases, the graft can be taken from the
patient’s own arm without any functional loss, and the tendon used is the
palmaris longus. In twenty percent of the patients, this tendon is not present
in which case an allograft tendon can be used. Alternatively a graft from the
patient’s leg can be used.
Arthritis
The goal is to identify which
portion of the joint needs to be replaced. If it is only a single portion of
the joint, for example the radial head, this can be replaced without having to
perform a major operation such as the total elbow replacement. Once the
arthritis involves the entire elbow, total joint replacement should be
considered. This can either be a constrained component, which means that the two
portions of the component lock together or an unconstrained component. The most
successful components to date have been the constrained components.
Who should consider treatment for elbow instability, and tendonitis? Elbow instability
Patients who are having regular symptoms or clinical
findings consistent with significant instability should consider ligament
reconstruction as this can minimize the problem of long-term arthritis and
relieve symptoms.
Elbow arthritis
Surgery is indicated for patients
who have had continued stiffness and pain so that routine functions of daily
life such as getting dressed, eating, and preparing food have become difficult.
The joint replacement will provide pain relief, but does not have enough
durability to allow the patient to resume sports such as golf or tennis, in most
cases.
Tendonitis
In most cases, conservative treatment is successful.
However, patients who have tried a 6-12 month course of therapy, including
non-steroidal anti-inflammatory medications and perhaps a steroid injection may
want to consider surgery to obtain pain relief.
What happens without surgery? Elbow instability
Progressive arthritis can develop if the ligaments are not
reconstructed. Once patients are symptomatic, surgery should be
considered.
If patients already have degenerative arthritis, in addition
to instability, it may be more practical to delay surgery and perform a total
elbow replacement.
Elbow arthritis
In general, delaying surgery does
not affect the overall options for reconstruction with elbow replacement.
Tendonitis
There are no long term adverse effects of delaying surgery
for tendonitis.
Surgical options Elbow instability
As noted above, the key options include the type of donor
material and additional devices to help fix or stabilize the tendon grafts to
the elbow. Autologous grafts are generally preferred, particularly when they can
be taken from the patient’s own arm, such as the palmaris longus tendon, which
causes no functional deficit to the patient. When this tendon is not available
or when there are multiple ligaments to reconstruct, the consideration of
allograft, which are grafts provided by a tissue donor, are very functional.
Additionally, tendon grafts can be harvested from the pateint’s leg.
Certain devices can help to fix and stabilize these ligaments to the
joint to provide additional stability in certain cases. These are called bone
anchors, which insert a device such as a screw or hook type of anchor into the
bone. The anchor has sutures attached to it that help provide secure fixation
of the tendon grafts down the bone.
Elbow arthritis
The key in elbow
arthritis is to determine the extent of the arthritis. If the arthritis is
limited to the radial head from an old fracture, simply replacing one segment of
the joint will be very successful.
Elbow arthritis involving the entire
elbow
In cases such as these as demonstrated in (Figures 3 and 4) the
only option is to replace the entire elbow as demonstrated in (Figure 5, 6,
and 7). In most cases, there is sufficient destruction of the adjacent
support ligaments that a replacement with a constrained component is advisable.
This component with two segments is locked together to prevent them from
dislocating between the portion attached to the humerus and the portion that
attaches to the ulna bone. When there is substantial bone destruction, but the
ligaments are still functioning, certain types of unconstrained components can
be inserted in rare circumstances.
Elbow tendonitis
The options for
this surgery are based on the location of the tendonitis. If the tendonitis
involves the lateral aspect of the elbow, the goal is to remove the inflamed
tissue and release the attachment of the extensor carpi radialis brevis. If it
is on the medial side of the elbow, the goal is also to remove inflamed and torn
tissues and reattach the elements of the two muscles attached to the medial or
inner side of the elbow, the flexor carpi ulnaris and the pronator teres.
Effectiveness Elbow instability
This operation is highly effective when performed by an
experienced surgeon and can restore nearly normal elbow function while limiting
the progression of arthritis.
Elbow arthritis
Surgery to replace
part, or the entire joint, can provide substantial pain relief. This operation
has demonstrated long-term effectiveness. The patients need to be cautioned
about limiting their extent of activities to prevent loosening of the total
elbow implants.
Tendonitis
Corrective surgery can provide long
lasting relief. It is important for the patients to follow the appropriate
exercise program to allow proper healing.
Urgency Elbow instability
Surgery for instability is not an emergency, but it should
not be unduly delayed. The patient should be in good health and understand the
risks and alternatives to surgery as well as understanding the post-operative
rehabilitation regimen in order to regain elbow motion.
Elbow
arthritis
This procedure is completely elective and should not be performed
unless the patient is finding that the arthritis is limiting their activities of
daily living. Again, the patient should be in optimal health, free from sources
of infection, such as recurring urinary tract infection, etc. The patient needs
to understand the risk of the surgery and the post-operative regimen and the
need to limit certain strenuous activities on a life long basis.
Tendonitis
There is no urgency to this procedure and no adverse
effects from delaying the surgery. The patient needs to have completed a
thorough conservative course of treatment and understand the risks of the
procedure. It is also important to recognize that the patient may not have
complete pain relief despite providing adequate surgical treatment.Risks The risk for each of these elbow reconstructions include but are not limited to
infection, injury of nerves and blood vessel, fractures, risk of anesthesia,
stiffness or instability of the elbow in arthritis surgery (where loosening of
the implants can occur). There is also risk associated with anesthesia and blood
transfusion (which is rarely required). A team experienced in treating elbow
problems use special techniques to minimize the risks, but cannot totally
eliminate them.
Managing risk Many of the complications of elbow surgery can be effectively managed if
identified and properly treated. If there is evidence of infection, early
treatment is recommended by taking the patient back to the operating room to
wash and clean the tissues. Blood vessel and nerve injury may require repair and
fracture can occur, particularly in elbow replacement surgery. Prosthetic
components may require surgical revision when implants are used, particularly
for elbow arthritis surgery. If there are questions or concerns about the course
after surgery, direct these to your surgeon as soon as possible.Preparation The best surgical results occur in healthy motivated patients who have had the
appropriate work up and initial treatment. It is important to recognize
potential sources of infection such as the bladder and the gums. The potential
for infection may be reason to delay surgery. The patient should not be on
anti-inflammatory medications prior to surgery, as these medications can result
in excessive bleeding after surgery. Aspirin and other anti-inflammatory
medications should be stopped at least seven days prior to surgery. The patient
needs to plan on less function than usual for twelve weeks after
surgery.
Driving, shopping, and performing usual chores may be difficult
during this time. Plans for necessary assistance need to be made before surgery.
For individuals who live alone or without readily available help, arrangements
for home help should be made well in advance.
Costs The surgeon's office should provide a reasonable estimate of:
- the surgeon's fee,
- the hospital fee, and
- the degree to which these should be covered by the patient's insurance.
Surgical team Elbow reconstructive surgery is technically demanding and should be performed by
an experienced surgeon in a medical center accustomed to performing
stabilization, reconstruction, and decompression. The surgeon should be
experienced with all matters of upper extremity surgery, including tendon repair
and reconstruction, nerve repair, and arterial repair as well as joint
replacement.Finding an experienced surgeon A surgeon who specializes in complex upper extremity reconstruction may be
located through University Schools of Medicine or the American Society for
Surgery of the Hand (www.assh.org).Facilities Elbow reconstruction is usually performed at a major medical center or hospital
that performs these procedures on a regular basis. These institutions have
surgical teams and facilities assigned for this type of surgery. They also have
the nurses and therapists who are accustomed to assisting patients in their
recovery.Anesthetic Elbow reconstructive surgery involves surgery that is performed critically close
to the nerves above the elbow. We recommend a general anesthetic so that
post-operatively the patient can be examined to determine that all the nerves
are functioning properly to prevent any undue pressure , irritation or injury
to the nerves.
Pain and pain management In order to minimize the pain and swelling from surgery, a small surgical drain
is usually placed in the wound and removed the day after surgery. Frequently,
the patient’s family can be instructed on how to remove this device without
causing the patient pain.
Most surgery for elbow instability and
tendonitis can be performed as an out-patient surgery with a regimen of
medication, including long acting medications such as (morphone SR long acting
morphine – get name from Josette) and short acting medicines such as Oxycodone.
Additional local anesthetics are used in surgery. For patients with total elbow
replacement, a hospital stay is recommended to administer IV intravenous
antibiotics for 48 hours after surgery, and to provide intravenous medication
such as morphine or Demerol.
Use of medications The use of pain medications can be varied. Typically, hospitalized patients
with total elbow replacement require two days of intravenous pain medication
and then are able to switch to oral pain medication. For patients with ligament
reconstruction or decompression and repair of tendonitis, oral pain medications
with a combination of short and long acting medications can be very effective.
Frequently, we will combine these with an anti-inflammatory medication to
provide an additional source of pain relief.Effectiveness of medications Pain medications can be very powerful and effective. Their proper use lies in
the balancing of their pain relieving effect and other less desirable effects.
Good pain relief is part of normal post-operative care.Important side effects Pain medications can cause drowsiness, slowness of breathing, and difficulties
in emptying the bladder and bowel, nausea, vomiting and allergic reactions.
Patients who have taken substantial narcotic medications in the recent past may
find that usual doses of pain medication are less effective. For some patients,
balancing the benefit and the side effects of pain medication is challenging.
Patients should notify their surgeon if they have had previous difficulties with
pain medication or pain control.Hospital stay As noted above, elbow ligament reconstruction for instability and tendon
decompression for tendonitis can be performed as outpatient surgery. Patients
frequently spend two days in the hospital after elbow replacement surgery.
Intravenous antibiotics are administered until the drains can be removed to
minimize the chance of infection. Intravenous analgesics are also administered
as needed.
Hospital discharge At the time of discharge, the patient should be relatively comfortable on oral
medications and have their appointment for therapy scheduled. For total elbow
replacement, therapy with general range of motion exercise should be started a
week after surgery and coordinated with a therapist who works regularly with the
surgeon with these type of patients.
Physical therapy Elbow instability
Early range of motion is begun within three to seven days
after surgery depending on the type and extent of the reconstruction. These
patients are protected in a long arm splint or split cast so they can remove the
splint and begin a range of motion program in order to avoid elbow stiffness. It
is particularly important to achieve elbow extension (that is to be able to
straighten the elbow fully).
Arthritis
Surgery with joint replacement:
For patients with limited joint replacement such as with the radial head,
exercises are started within two to three days after surgery. For total elbow
replacement surgery, the range of motion exercises are started approximately one
week after surgery. When the patient is not exercising the elbow, a posterior
splint will help support the elbow and prevent injury from contact.
Decompression of tendonitis of the elbow:
These patients are placed
in a splint to allow them to be comfortable and to reduce swelling. Then,
approximately one to two weeks after surgery, general stretching exercises are
begun. The patient is not splinted and allowed to regain their full elbow
motion. Strenuous exercises are delayed for six to eight weeks and full strength
is not expected to return until three months after surgery.
Rehabilitation options: Exercises are both supervised by a therapist and
coupled with an exercise program that can be done at home. The therapist
provides regular measurements and monitors the wound for healing.
Usual response The patients are generally satisfied with the improvement of their motion and
stability. It is key to have the patients work to maximize their range of motion
within four weeks after the surgery. Delays in achieving full extension or
flexion after this time can result in permanent loss of motion.
Risks The rehabilitation program is generally achieved with minimal risk, particularly
when supervised by a knowledgeable therapist.Duration of rehabilitation The duration of a rehabilitation program can extend from six to twelve weeks
depending on the extent of surgery and difficulty in regaining motion. Returning to ordinary daily activities The outpatients are able to perform general activities of daily living with the
operative arm at the side two to three weeks after surgery. Walking with the arm
protected is strongly encouraged; driving should wait until the patient can
perform the necessary functions comfortably and confidently. This may take up to
one month after surgery if performed on the right extremity because of the
demands of operating a vehicle. With the consent of the surgeon, patients with
elbow ligament reconstruction and tendonitis decompression can return to full
activities within six months after surgery. Patients with elbow replacement
surgery should refrain from activities requiring repetitive impact on the
extremity, and even golf and tennis are not advised.
Costs The surgeon and therapist should provide information to the patient about the
usual cost of the rehabilitation program. The program is quite cost effective
because it does incorporate a home exercise program along with a supervised
program with a therapist.Surgery for Elbow Instability, Arthritis, and Tendonitis at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-4537 to make an appointment.
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