DEAR MAYO CLINIC: I have bad arthritis in my elbow. After several failed surgeries, I have been told that my only option is elbow replacement. I've heard others say that elbow replacements do not work. Does Mayo Clinic have experience with elbow replacements?

ANSWER: The surgeons at Mayo Clinic are considered world experts in elbow replacement. Traditionally, elbow replacement has been reported to lead to complications more often than replacements of other joints, like the hip or knee. However, modern elbow replacements provide a reliable solution for many patients, and the complication rate with Mayo Clinic patients has decreased.

First and foremost, it is important to make sure your elbow is ready for replacement. Pain and motion in arthritic elbows can be improved tremendously using an alternative procedure called arthroscopic osteocapsular arthroplasty, where a camera is inserted in the joint and instruments are introduced through small skin cuts to essentially clean the joint. This procedure allows the surgeon to remove bone spurs, fragments of bone or cartilage, and inflamed tissue.

Unfortunately, in many circumstances, the elbow is severely damaged. Elbow replacement is the best option in these cases.

Three bones form part of the elbow joint: the arm bone, also known as the humerus; and the two bones in the forearm, the radius and ulna. The ulna and the humerus form a hingelike joint for elbow bending and straightening. The radius supports the wrist and helps the palm of the hand rotate up and down. Elbow replacements provide a new joint between the humerus and the ulna. In certain circumstances, the upper end of the radius, the radial head, is replaced to avoid any long-term complications, as well.

Typically, the procedure is performed under general anesthesia through an incision in the back of the elbow. The bones in the elbow are prepared to receive the implants, which are fixed with bone cement. A high-quality plastic liner forms the new joint against metal. Once the wound is healed, it takes about three months of physical therapy to restore elbow motion, and most patients' pain completely resolves. However, complications to watch for include infection, nerve injury, tendon injury, and implant wear or loosening.

Infection is particularly worrisome in people with rheumatoid arthritis who take medications that affect the immune system. It is also a concern when replacement is performed in elbows that already have been operated on several times. Every effort is made at Mayo Clinic to prevent infection, including careful evaluation of the elbow for possible occult infection when needed, use of antibiotics locally in the wound in addition to through an IV, and meticulous care of the surgical wound.

Complete nerve palsy is a rare complication of elbow replacement. However, one of the nerves of the arm — the ulnar nerve — is close to the joint. This nerve is sensitive, and some patients may experience partial loss of feeling or tingling in the ring and small fingers for a few months after surgery. Sometimes this loss can be permanent.

To access the elbow joint, the triceps muscle or tendon oftentimes is detached from the bone or divided at the time of replacement. The triceps is reattached or repaired at the end of the procedure, and it heals in most, but not all, patients. When the triceps does not heal, patients may feel weakness with activities that require extending the elbow, such us opening a door or holding objects overhead. One major advance in Mayo Clinic's practice has been to develop alternative ways to deal with the triceps at the time of the replacement to minimize weakness.

Finally, like other replacements, elbow implants are mechanical devices that are subject to wear and tear after years of use. Luckily, higher-performance implants are available that likely will last much longer. However, common sense would suggest avoiding use of the replaced elbow for high-demand activities, such as weight training or hard manual labor, if possible.

The good news is that people who suffer with pain and stiffness due to severe elbow arthritis are seldom disappointed with the results of elbow replacement: Pain goes away, and movement allows most activities to be performed. The key for success is to place your confidence in a surgeon who performs this procedure regularly and has developed techniques to minimize complications.

An elbow replacement is a wonderful procedure for those who need it, and it can provide significant improvement in quality of life from the effects of arthritis. — Dr. Joaquin Sanchez-Sotelo, M.D., Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota

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