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 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.
Considering surgeryWhat kinds of surgery are recommended for elbow instability, arthritis, and tendonitis ? 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 for elbow instability, arthritis, and tendonitis and in what cases? 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 if nothing is done for elbow instability, arthritis, and tendonitis (best case/worst case scenarios)? 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.
What options exist for surgery for elbow instability, arthritis, and tendonitis ? 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.
When performed by an experienced surgeon, how effective is treatment for elbow instability, and tendonitis for elbow instability, arthritis, and tendonitis likely to be and how long will the benefit last? 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.
How urgent is treatment for elbow instability, and tendonitis for elbow instability, arthritis, and tendonitis ? 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.What are the most frequent and most serious risks of treatment for elbow instability, and tendonitis for elbow instability, arthritis, and tendonitis ? How common are they? 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.
If risks occur during or after treatment for elbow instability, and tendonitis for elbow instability, arthritis, and tendonitis how are they managed? 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.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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