Elbow Surgery

Biceps Tendon Tear at Elbow

Surgical Treatment

Goal - The aim of surgical treatment is to return the patient to normal function by reattaching the tendon to where it normally connects on the forearm near the elbow joint.

Timing - Outcome and recovery is improved when there is little delay in receiving treatment. Surgery should occur within the first two weeks after injury. A longer delay can cause scarring of the contracted muscle and tendon, which in turn can make surgery more difficult to perform. With long treatment delays, it may be impossible to stretch the tendon back to its normal attachment site. Biceps tendon rupture repair is easier to perform before scar tissue has started to form.

Procedure - No one method is considered the best overall for repairing a ruptured biceps tendon; therefore, the selection of the surgical procedure to use is typically left to the surgeon. One method involves placing suture material in the tendon to grab it, and then attaching the tendon to the bone through drill holes. Another method requires tying the tendon down to man-made devices that are left in place permanently.

Rehabilitation - The orthopaedic surgeon may recommend physical therapy, splints, or slings, depending on the individual patient. Physical therapy may help patients to regain range of motion and strength. Splints or slings can be used for initial rest and for guiding and protecting the injury after motion is resumed. The period of complete rest after surgery should not be too long because some decrease in elbow motion from scarring can occur.

Recovery - Because it takes months for the tendon to reform a strong attachment to the bone, the recovery phase is quite long. During recovery, vigorous use of the arm, especially for pulling and lifting, should be avoided. A gradual increase in motion and strength training is required.

Distal Biceps Tendon Rupture

Surgical Treatment

Most patients will experience benefit if the biceps tendon is repaired surgically. If the tear is incomplete, or if the patient is very low-demand (not active), then surgery may not be needed. However, most patients who want more normal use of their arm will benefit from surgery to repair the ruptured tendon to the bone.

Elbow (Olecranon) Bursitis

Surgical Treatment

If the bursa is infected and it does not improve with antibiotics or by removing fluid from the elbow, surgery may be needed. This is an inpatient procedure.

If elbow bursitis is not a result of infection, surgery may still be needed if nonsurgical treatments don't work. Surgery to remove the bursa is usually performed as an outpatient procedure. The surgery does not disturb any muscle, ligament, or joint structure.

Elbow Fractures in Children

If a child complains of elbow pain after a fall and refuses to straighten his or her arm, see a doctor immediately. The doctor will first check to see whether there is any damage to the nerves or blood vessels. X-rays will help determine what kind of fracture occurred and whether the bones moved out of place. Because a child's bones are still forming, the doctor may request X-rays of both arms for comparison.

Surgical Treatment

Treatment depends on the type of fracture and the degree of displacement. If there is little or no displacement, the doctor may immobilize the arm in a cast or splint for 3 to 5 weeks. During this time, another set of X-rays may be needed to determine whether the bones are staying properly aligned.

If the fracture forced the bones out of alignment, the doctor will have to manipulate them back into place. Sometimes, this can be done without surgery, but more often, surgery will be needed. Pins, screws, or wires are used to hold the bones in place.

The child will have to wear a cast for several weeks before the pins are removed. Range of motion exercises can usually begin about a month after surgery.

Elbow (Olecranon) Fractures

Surgical Treatment

Surgery to treat an olecranon fracture is usually necessary when:

• The fracture is out of place
• The fracture includes an open wound

Technique - Surgery can be done under general anesthesia or under regional anesthesia or both.

During surgery the patient may lie on his/her back, side, or stomach. If the patient lies on his/her belly, the face may become swollen for a few hours after the operation is over. This is normal and temporary.

The surgeon will typically make an incision over the back of the elbow and then put the pieces of bone back together. There are several ways to hold the pieces of bone in place.

The surgeon may choose to use: pins, wires, screws, plates, or sutures.

If some of the bone is missing or crushed beyond repair (pieces of bone lost through a wound during an accident), the fracture may require bone filler. Bone filler can be bone supplied by the patient (typically taken from the pelvis) or bone from a donor, or an artificial calcium-containing material.

The incision is typically closed with sutures or staples. Sometimes, a splint is placed on the arm, but not always.

Considerations - Surgery has some risks. If surgery is recommended, the doctor feels that the possible benefits of surgery outweigh the risks.

• Infection

• Pain is associated with surgery
• Damage to nerves and blood vessels (This is an unusual side effect.)

Tennis Elbow (Lateral Epicondylitis)

Surgical Treatment

Surgery is considered only in patients who have incapacitating pain that does not get better after approximately six months of nonsurgical treatment.

The surgical procedure involves removing diseased tendon tissue and reattaching normal tendon tissue to bone. The procedure is an outpatient surgery, not requiring an overnight stay in the hospital. It can be performed under regional or general anesthesia.

Most commonly, the surgery is performed through a small incision over the bony prominence on the outside of the elbow. But an arthroscopic surgery method has been developed as of recent.

Osteoarthritis of the Elbow

Surgical Treatment

When nonsurgical interventions are not enough to control symptoms, surgery may be needed. By the time arthritis can be seen on X-rays, there has been significant wear or damage to the joint surfaces. If the wear or damage is limited, arthroscopy can offer a minimally invasive surgical treatment. It may be an option for patients with earlier stages of arthritis.

Arthroscopy has been shown to provide symptom improvement at least in the short term. It involves removing any loose bodies or inflammatory/degenerative tissue in the joint. It also attempts to smooth out irregular surfaces. Multiple small incisions are used to perform the surgery. It can be done as an outpatient procedure, and recovery is reasonably rapid.

If the joint surface has worn away completely, it is unlikely that anything other than a joint replacement would bring about relief. There are several different types of elbow joint replacement available.

In appropriately selected patients, the improvement in pain and function can be dramatic. With an experienced surgeon, the results for elbow joint replacement are typically as good as those for hip replacement and knee replacement.

For patients who are too young or too active to have prosthetic joint replacement, there are other reasonably good surgical options. If loss of motion is the primary symptom, the surgeon can release the contracture and smooth out the joint surface. At times, a new surface made from the patient's own body tissues can be made. These procedures can provide years of symptom improvement.

Ulnar Nerve Entrapment

Surgical Treatment

If the strategies listed above do not help improve the condition, if the nerve is very compressed, or if there is muscle wasting, the doctor may recommend surgery to take pressure off of the nerve.

Most often, the surgery is done around the elbow, but it can be done at the wrist, if that is the place of the compression. Sometimes, the nerve is compressed in both places, so surgery is done at both the elbow and the wrist.

Surgeons use various ways to relieve compression from the nerve around the elbow. All of the operations involve making an incision around the elbow.

In one operation, only the " roof " is taken off of the cubital tunnel. This tends to work best when the nerve compression is mild.

More commonly, the nerve is moved from its place behind the elbow to a new place in front of the elbow. This is called an anterior transposition of the ulnar nerve. The nerve can be moved to lie under the skin and fat but on top of the muscle (subcutaneous transposition), within the muscle (intermuscular transposition) or under the muscle (submuscular transposition). There are many factors that go into deciding where the nerve is moved. The doctor will recommend the best option for you.

If the nerve is compressed at the wrist, a zigzag incision will be made at the base of the palm on the little finger side of the hand. The surgeon will open the roof of Guyon's canal to take the pressure off the ulnar nerve. If there is a cyst or another reason for the compression, the surgeon will remove that at the same time.

The surgery is usually done on an outpatient basis or with an overnight stay in the hospital. Depending on the type of surgery, you may need to wear a splint for a few weeks after the operation. A submuscular transposition usually requires a longer time (three to six weeks) in a splint.

The surgeon may recommend physical therapy to help regain strength and motion in the arm.

The results of the surgery are generally good. If the nerve is very badly compressed or if there is muscle wasting, the nerve may not be able to return to normal and some symptoms may remain even after the surgery. Nerves recover slowly, and it can take a long time to know how well the nerve will do after surgery.

Total Elbow Replacement Surgery

Getting to the Joint

The patient is first taken into the operating room and given anesthesia. After the anesthesia has taken effect, the skin around the elbow is thoroughly scrubbed and sterilized with an antiseptic liquid. A tourniquet is then applied to the upper portion of the arm to help slow the flow of blood.
An incision about six inches long is then made over the elbow joint. The incision is gradually made deeper through muscle and other tissue until the bones of the elbow joint are exposed.

Preparing the Bones

One of the forearm bones, the ulna, has a projection at the end, which extends up and behind the end of the humerus. A special power saw is used to remove part of this projection.
This allows the two forearm bones to be rotated out of the way so parts of the humerus can be removed with the saw. Precision guides are used to help make sure that the cuts are made so the bones will align properly after the implant is inserted.

The middle portion at the end of the humerus is removed first.
The arm bones have relatively soft, porous bone tissue in the center. This part of the bone is called the "canal." Special instruments are used to clear some of this soft bone from the canal of the humerus. These instruments also help shape the canal to fit the shape of the implant.
Then, similar instruments are used to clear some of the soft bone and shape the canal of the ulna.

Attaching the Implants

The elbow implant consists of two metal stems that are connected by a metal locking pin. This pin passes through the ends of both stems, which are lined with a strong plastic material, serving as a bearing that allows the elbow to bend. The stems are inserted into each of the two prepared canals. A special kind of cement for bones is first injected into the canals to help hold the stems in place.
When the cement is hard, the two implant parts are brought together and the pin is inserted to connect them.

Closing the Wound

If necessary, the surgeon may adjust the ligaments that surround the elbow to achieve the best possible elbow function.

When all of the implants are in place and the ligaments are properly adjusted, the surgeon sews the layers of tissue back into their proper position. A plastic tube may be inserted into the wound to allow liquids to drain from the site during the first few hours after surgery. The edges of the skin are then sewn together, and the elbow is wrapped in a sterile bandage. Finally, the patient is taken to the recovery room.