Mayo Surgeons Turn Away From Elbow Replacements

Elbow replacements are available for younger adults (less than 40 years old) but results have not been great. Studies show that success rates are getting better but may not be good enough yet. At the Mayo Clinic, less than 10 per cent of the patients who received a total elbow replacement over a 20-year period were 40 years old or younger. The surgery was done to save the elbow.

All of the 55 patients in this Mayo study had severe osteoarthritis, nonunion of bone fracture at the elbow, or severe joint instability. They either had severe inflammatory or posttraumatic arthritis. Most of the patients had at least one previous elbow surgery. Some had several (up to six) prior surgeries. They were considered good candidates for a salvage procedure such as total elbow arthroplasty (TEA).

And despite 92 per cent of the group scoring good-to-excellent on the Mayo Elbow Performance Score (MEPS), there was still a 22 per cent revision rate. The surgeons consider this unacceptable and suggest pursuing non-replacement options for as long as possible.

The MEPS measures motion, joint stability, and ability to perform daily activities. Other measures used to assess outcome included X-rays of the implant and pain. X-rays show areas of radiolucency around the implant indicating greater transparency and less bone density. A small number of patients had a complete radiolucent line around one side of the elbow replacement. This is a sign of implant loosening.

MEPS scores improved after the elbow replacement. Before surgery, patients in both groups had great difficulty just doing simple things like combing their hair, feeding themselves, and getting dressed in the morning. The posttraumatic group had the greatest motion restrictions both before and after surgery (compared with the inflammatory group).

Complications requiring revision surgery included deep infection, implant loosening, triceps weakness, and implant wear. Again, the group with posttraumatic arthritis was more likely to develop problems leading to a second surgery. In other words, they had a much higher complication rate.

The authors conclude by saying the surgical treatment of elbow arthritis is very difficult. There really aren't very many good options. But before replacing the elbow, they suggest trying a synovectomy or interposition arthroplasty whenever possible. Synovectomy is the partial removal of the synovial membrane that lines the non-cartilaginous surfaces within joints like the elbow. Usually the head of the radius (top of the forearm bone at the elbow) is removed at the same time.

Interpositional arthroplasty is the removal of the damaged joint and placement of a rolled up tendon (or other soft tissue) in the empty joint space. The main goal of interposition surgery is to ease pain where the surfaces of the elbow joint are rubbing together. The piece of tendon forms a "spacer" that separates the surfaces of the joint. This procedure is not recommended if the patient has significant bone loss, gross joint instability, or a severe elbow deformity.

Even with the high complication and revision rates, there is still a place for elbow replacement in younger patients. Those with advanced arthritic disease who have already failed nonreplacement options may still be aided by a joint replacement. It is certainly preferred over an elbow fusion since the fusion eliminates elbow motion and creates a functionally disabling condition.

References: Andrea Celli, MD, and Bernard F. Morrey, MD. Total Elbow Arthroplasty in Patients Forty Years of Age or Less. In The Journal of Bone and Joint Surgery. June 2009. Vol. 91A. No. 6. Pp. 1414-1418.