Elbow Replacement Surgery
Surgical Treatment from an Adelaide Elbow Specialist
If your elbow joint is ruined by severe arthritis, a complex fracture, or long-term wear, it can become stiff, painful, and nearly unusable. Elbow replacement surgery (elbow arthroplasty) replaces the damaged joint with artificial components, helping restore the elbow's ability to bend and straighten and, most importantly, relieving pain. In a total elbow replacement, both sides of the joint are replaced with metal and plastic components. For some complex fractures, a hemiarthroplasty replaces only the broken end of the humerus.
Pre-surgical considerations
You might consider this surgery if:
- All conservative treatments—like medications, physio, or injections—no longer relieve your pain or stiffness.
- Severe joint damage is confirmed on X-rays or scans.
- Conditions like osteoarthritis, rheumatoid arthritis, or a badly injured elbow are significantly limiting your daily life.
Before proceeding with elbow replacement surgery, thorough pre-surgical evaluations and considerations are essential. Key elements of this phase include:
Medical evaluation: The orthopaedic surgeon reviews the patient's medical history and conducts a comprehensive physical examination to assess the extent of joint damage and overall health.
Imaging studies: X-rays, MRI, or CT scans are performed to obtain detailed images of the elbow joint, aiding in surgical planning.
Patient education: The surgeon discusses the surgical options, potential risks, and expected outcomes with the patient, allowing them to make informed decisions about their treatment.
Day of surgery considerations
On the day of elbow replacement surgery, the following considerations are made:
Anaesthesia: Patients are administered either general anaesthesia or regional anaesthesia (nerve block) to ensure their comfort and pain management during the procedure.
Surgical procedure: Dr Oscar Brumby-Rendell performs the surgery, making an incision over the elbow joint. The damaged bone and cartilage are removed, and the artificial implant, comprising metal and plastic components, is meticulously positioned to recreate the elbow joint's smooth functioning.
Surgical approach: The surgical approach may be either "triceps on" or "triceps off", with the latter being the classic approach. However, newer techniques involving a "triceps on" approach are gaining popularity due to reduced post-surgery weakness of elbow extension.
Post-surgery rehabilitation
Full recovery after an elbow replacement generally takes up to 12 months. Rehabilitation is staged to protect the new joint while you rebuild movement and strength:
- Weeks 0–2 (protect and prevent stiffness): elevation and swelling control, hand, wrist and shoulder exercises, and gentle elbow and forearm movement within comfort. No pushing up from a chair through the arm.
- Weeks 2–6 (increase range of motion): physiotherapy starts once the wound has healed, with progressive elbow and forearm range of motion, light everyday use for eating and grooming, and gentle isometric exercises. No resisted triceps strengthening.
- Weeks 6–12 (strength and conditioning): light resistance-band strengthening, grip strengthening and functional reaching to restore independence in daily activities.
- Months 3–6 (return to activity): progressive light strengthening and endurance work for comfortable independent function, while avoiding excessive load through the implant.
Key milestones: a sling for 4–6 weeks, mainly for comfort; no lifting or pushing more than 0.5 kg for 6 weeks; driving at around 6 weeks, once you're out of the sling and can safely control the wheel; desk work after 2–3 days. After a total elbow replacement, a lifelong lifting limit of about 5 kg protects the implant. Heavy upper-body gym work is not recommended.
See the full rehabilitation plans.
Longevity of implant
Advancements in implant designs have contributed to increased implant longevity. The use of linked prostheses has led to a much lower failure rate of elbow replacement. The improved components and fixation techniques have resulted in:
- Reduced wear: Modern materials, such as metal alloys and high-grade polyethylene, have lower wear rates, minimising the risk of implant wear and loosening over time.
- Enhanced stability: Advanced fixation methods, including cementless and cemented options, provide improved stability, leading to a longer-lasting implant.
- Lower revision rates: New elbow replacements have demonstrated lower rates of revision surgery due to their improved designs and better fixation.
Surgical implants and approach
New elbow replacement designs have shown promising results with lower failure rates. Linked prostheses have played a significant role in improving the longevity of elbow replacements, reducing the need for revision surgery.
Surgical approaches
The two main surgical approaches for elbow replacement are "triceps on" and "triceps off". The traditional "triceps off" approach involves detaching and then repairing the triceps tendon, which can result in weakness of elbow extension post-surgery. On the other hand, the "triceps on" approach involves leaving the triceps intact, reducing post-surgery weakness. Although the "triceps on" approach may require slightly more technical expertise, it offers significant advantages in terms of post-surgery recovery and improved elbow function.
Elbow hemiarthroplasty for complex fractures
Not every elbow replacement needs to replace both sides of the joint. When a fracture shatters the lower end of the humerus (the distal humerus) and the pieces are too small or too damaged to be fixed with plates and screws, one option is a distal humeral hemiarthroplasty. Only the broken end of the humerus is replaced, with a metal component shaped like the natural joint surface. The ulna and radius, and their cartilage, are left untouched.
Hemiarthroplasty is considered for distal humerus fractures that cannot be reliably reconstructed, where the ligaments and the joint surfaces of the forearm bones are in reasonable condition. Because there is no hinge to wear out or loosen, it can suit people who rely on their arms to get around, such as those using a walking frame or crutches, and younger, more active people who would find the lifting restrictions of a total elbow replacement difficult to live with. Where a fracture can be fixed well, fixation remains the first choice.
How it differs from a total elbow replacement
| Hemiarthroplasty | Total elbow replacement | |
|---|---|---|
| What is replaced | Lower end of the humerus only | Humerus and ulna, joined by a linked hinge |
| Your own cartilage | Ulna and radius preserved | Ulnar joint surface removed |
| Long-term lifting limit | No lifelong weight limit | Lifelong limit of about 5 kg to protect the hinge |
| Main long-term concern | Wear of the ulnar cartilage; instability | Loosening and wear of the linked components |
| If revision is needed | Often an ulnar component is simply added, keeping the original humeral implant | Commonly involves exchanging the humeral or ulnar components |
What the evidence shows
- Similar function to total elbow replacement. A multicentre randomised trial of 40 patients aged 60 and over found good, similar function with either operation at a minimum of two years (DASH score 21.6 for hemiarthroplasty and 27.2 for total elbow replacement, with no significant difference).1
- Lower revision rate in Australian registry data. An analysis of 906 elbow replacements for fracture from the Australian Orthopaedic Association National Joint Replacement Registry found a 9-year revision rate of 9.7% for hemiarthroplasty and 11.9% for total elbow replacement. After the first three months, total elbow replacements were about 2.5 times more likely to need revision, and about 4 times more likely to be revised for loosening.2
- Simpler revision when needed. In the same registry, the most common revision after hemiarthroplasty was adding an ulnar component while keeping the original humeral implant.2
- Consistent results across studies. A systematic review and meta-analysis of 29 studies in patients over 65 found Mayo Elbow Performance Scores of 87 for hemiarthroplasty and 88.3 for total elbow replacement, with patient-reported outcomes and range of motion mostly favouring hemiarthroplasty.3
- Active patients. In patients under 55, hemiarthroplasty produced satisfactory outcomes and allowed a higher level of activity than is generally advised after total elbow replacement.4
Recovery
Rehabilitation after a hemiarthroplasty follows the same staged programme as a total elbow replacement, described above: a sling for 4 to 6 weeks, mainly for comfort, physiotherapy from about two weeks once the wound has healed, no lifting or pushing more than 0.5 kg for 6 weeks, and driving at around 6 weeks. The main difference is that there is no lifelong 5 kg lifting limit.
Risks to be aware of
Complex elbow fractures are serious injuries, and complications are common after any operation for them. After hemiarthroplasty, reported problems include wear of the ulnar cartilage, extra bone forming around the elbow (heterotopic ossification), irritation of the ulnar nerve, stiffness and instability. A systematic review of 163 patients reported a major complication rate of 11%, alongside good average function scores.5 Overall complication rates are similarly high for both operations,3 which is why the choice is made individually, based on the fracture pattern, bone quality, your age and what you need your arm to do.
- Jonsson EÖ, et al. Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial. J Shoulder Elbow Surg 2024;33(2):343–355.
- Taylor F, Page R, Wheeler J, et al. Distal humeral hemiarthroplasty compared to total elbow replacement for distal humeral fractures: a registry analysis of 906 procedures. J Shoulder Elbow Surg 2023. doi:10.1016/j.jse.2023.08.001
- Burden EG, Batten T, Smith C, Evans JP. Hemiarthroplasty or total elbow arthroplasty for unreconstructable distal humeral fractures in patients aged over 65 years: a systematic review and meta-analysis. Bone Joint J 2022;104-B(5).
- Smith GC, Bayne G, Page R, Hughes JS. The clinical outcome and activity levels of patients under 55 years treated with distal humeral hemiarthroplasty for distal humeral fractures: minimum 2-year follow-up. Shoulder Elbow 2016;8:264–270.
- Wilfred AM, Akhter S, Horner NS, et al. Outcomes and complications of distal humeral hemiarthroplasty for distal humeral fractures – a systematic review. Shoulder Elbow 2022;14:65–74.
Frequently Asked Questions
It's not advised to drive until you can fully control your arm and react quickly in an emergency, often several weeks after surgery. Your surgeon will guide you on when it’s safe based on your recovery progress.
Post-elbow replacement care with Dr Oscar Brumby-Rendell rehabilitation
Elbow replacement surgery offers an effective solution for patients suffering from severe elbow joint damage. Advancements in implant designs and surgical approaches have contributed to improved outcomes and reduced revision rates. Pre-surgical evaluations, proper rehabilitation, and the use of linked prostheses have played a crucial role in the success of elbow replacements. As medical technology continues to progress, patients can expect even better outcomes and restored elbow function following total elbow arthroplasty.
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