Elbow Surgery

What is Elbow Surgery?

Elbow surgery is a surgical procedure for the treatment of an elbow injury or elbow condition. The procedure involves repairing a diseased, damaged, or degenerated elbow joint in order to eliminate pain and restore normal function.

The elbow is a complex joint formed by the articulation of three bones: the humerus, radius, and ulna. Articular cartilage lines the articulating regions of these three bones. It is a thin, tough, flexible, and slippery surface that acts as a shock absorber and cushion to reduce friction between the bones. The elbow joint helps in bending or straightening of the arm to 180 degrees and lifting or moving objects. The bones of the elbow are supported by ligaments, tendons, muscles, nerves, and blood vessels. Any damage to elbow bones and their supporting structures can significantly affect the mobility and function of the elbow joint, necessitating elbow surgery.

Indications for Elbow Surgery

Elbow surgery is indicated when non-surgical treatment such as medications, injections, physical therapy, closed reduction, or manipulation have proved unsuccessful in treating the following elbow conditions:

• Elbow fractures: A fracture or broken bone is a common elbow injury. Elbow fractures can result from a fall onto an outstretched wrist, a direct impact to the elbow, or twisting injury. Elbow fractures can cause severe pain, swelling, and tenderness. Surgery is often required if a bony displacement is observed. 
• Tennis elbow: Tennis elbow is a common name for an elbow condition called lateral epicondylitis. It is an overuse injury that causes inflammation and microtears of the tendons that attach to the lateral epicondyle. It is a painful condition caused by repeated muscle contractions at the forearm.
• Golfer’s elbow: Golfer’s elbow, also called medial epicondylitis, is a painful condition occurring from repeated muscle contractions in the forearm that cause inflammation and microtears in the tendons that attach to the medial epicondyle.
• Elbow (Olecranon) bursitis: The elbow contains a large, curved, pointy outer bone called the olecranon, which is covered by the olecranon bursa, a small fluid-filled sac that allows smooth movement between the bone and overlying skin. Inflammation of the olecranon bursa leads to a condition called olecranon bursitis.
• Elbow dislocation: Elbow dislocation occurs when the bones that make up the joint are forced out of alignment, usually as a result of a fall onto an outstretched hand. It can also occur from a traumatic injury such as a motor vehicle accident. When the elbow is dislocated you will experience severe pain, swelling, and an inability to bend your arm.
• Cubital tunnel syndrome/Ulnar nerve entrapment: The ulnar nerve travels down the back of the elbow behind a bony bump called the medial epicondyle, and through a passageway called the cubital tunnel. When the elbow is bent, the ulnar nerve can stretch and catch on this bony bump. When the ulnar nerve is compressed or entrapped, the nerve can tear and become inflamed, leading to cubital tunnel syndrome.
• Elbow arthritis: Arthritis is one of the common disease conditions affecting the elbow joint. There are several types of arthritis, the two most common being:
  • Osteoarthritis or degenerative joint disease is the most common type of arthritis that affects the elderly. It causes the cartilage, the tissue that cushions and protects the ends of the bones in a joint, to wear away, causing painful rubbing of the bones.
  • Rheumatoid arthritis is an autoimmune disease in which the body’s immune system attacks healthy joints, tissues, and organs. It can cause pain, stiffness, swelling, deformity, and loss of function in the joints.

Preparation for Elbow Surgery

Preoperative preparation for elbow surgery may involve the following steps:

• A thorough examination is performed by your doctor to check for any medical issues that need to be addressed prior to surgery.
• Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could compromise the safety of the procedure.
• You will be asked if you have allergies to medications, anesthesia, or latex.
• You should inform your doctor of any medications, vitamins, or supplements you are taking.
• You may be asked to refrain from supplements or medications such as blood-thinners or anti-inflammatories for a week or two prior to surgery.
• You should refrain from alcohol or tobacco at least a few days prior to surgery.
• You should not consume any solids or liquids at least 8 hours prior to surgery.
• Arrange for someone to drive you home after surgery, as you may be groggy.
• A written consent will be obtained from you after the surgical procedure has been explained in detail.

Procedure for Elbow Surgery

Based on your elbow condition, several types of elbow surgeries can be performed to address the elbow condition. Elbow surgery is performed under general or local anesthesia either as an open surgery or as a minimally invasive arthroscopic procedure.

In an arthroscopic procedure, tiny incisions (portals), about a half-inch in length, are made around the joint area. Through one of the incisions, an arthroscope - a small flexible tube with a light and video camera at its end - is passed into the joint. The camera displays the images of the inside of the joint on a monitor, allowing your surgeon to view the damage and carry out the required repair.

In an open surgery, a long incision of several centimeters is made over the joint. The underlying soft tissues are carefully moved aside to expose the treatment area. Special surgical tools are used to carry out the required repair around the joint. Once the repair is complete, the instruments are removed and the incisions are closed with stitches or small sterile bandage strips.

Common elbow surgeries include:

Elbow replacement surgery: This is a surgery commonly employed for the treatment of elbow joint arthritis or damage to the elbow joint as a result of severe trauma or fracture. In this surgery, the damaged articulating parts of the elbow joint are removed and replaced with artificial prostheses to restore elbow function.

Cubital tunnel release surgery: This is a surgery performed for the treatment of cubital tunnel syndrome/ulnar nerve entrapment. The goal of cubital tunnel surgery is to reduce the pressure on the ulnar nerve by providing more space for the nerve to move freely and to increase blood flow for the ulnar nerve to heal. There are different surgeries that can be performed to treat your condition, such as:

• Medial epicondylectomy: This surgery involves removing the medial epicondyle, the bony bump on the inside of the elbow, enabling the ulnar nerve to glide smoothly when the elbow is flexed and straightened.
• Ulnar nerve transposition: This procedure involves creating a new tunnel in front of the medial epicondyle and transposing (moving) the ulnar nerve to the new tunnel.

Your surgeon will decide which option is best for you depending on your specific circumstances.

• Lateral epicondyle release surgery: This is a surgery performed for the treatment of Tennis elbow. During this surgery, your surgeon moves aside soft tissues to view the extensor tendon and its attachment on the lateral epicondyle, and then trims or releases the tendon, and reattaches it to the bone. Any scar tissue present will be removed as well as any bone spurs.
• Bursectomy: This is a surgery employed for the treatment of olecranon/elbow bursitis and involves making an incision of 10 cm over the back of the elbow and removing the inflamed bursa. Your surgeon may also remove other structures pressing on the bursa and causing inflammation such as a bone spur.
• Distal biceps tendon repair: The biceps tendon that attaches the muscle at the elbow is known as the distal biceps tendon. Tears of the distal biceps tendon are usually complete and the muscle is separated from the bone, requiring surgical intervention. During distal biceps tendon repair, the tendon is reattached to the forearm bone with stitches through holes drilled inside the bone or small metal implants used to attach the tendon to the bone.
• UCL reconstruction surgery: The ulnar collateral ligament (UCL), also called medial collateral ligament, is located on the inside of the elbow and connects the ulna bone to the humerus bone. It is one of the main stabilizing ligaments in the elbow. Serious rupture of this ligament warrants immediate surgical intervention. UCL reconstruction surgery involves replacing a torn ulnar collateral ligament with a tendon from elsewhere in the body. It is also referred to as Tommy John Surgery.

Postoperative Care and Recovery

In general, postoperative care instructions and recovery after elbow surgery will involve the following steps:

• You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anesthetic reactions and monitor your vital signs as you recover.
• Most patients will be discharged the same day of the surgery, however, some may require an overnight hospital stay.
• You may notice some pain, swelling, and discomfort in the operated area. Pain and anti-inflammatory medications are provided as needed.
• You will be placed in a sling for the first few days with instructions on restricted activities.
• You are advised to keep your arm elevated above your chest for a day or two while resting to prevent swelling and pain.
• You may be advised to wear a splint on your elbow for a couple of weeks to help the area heal.
• You are encouraged to gently exercise your fingers, elbow, and shoulder to prevent stiffness.
• Application of ice packs on the operated area is also advised to prevent stiffness and swelling.
• Physical therapy and range of motion exercises are recommended to restore mobility and strengthen the elbow joints and muscles.
• You should keep your surgical site clean and dry for at least 48 hours. Instructions on surgical site care and bathing will be provided.
• Refrain from strenuous activities or lifting heavy objects for at least a month. Gradual increase in activities over a period of time is recommended.
• You will be able to resume your normal activities within a week.
• Most patients are able to resume their normal activities in a month or two after surgery; however, you may have certain activity restrictions, and return to sports may take at least 6 months or longer.
• A periodic follow-up appointment will be scheduled to monitor your progress.

Risks and Complications

Elbow surgery is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as:

• Pain
• Bleeding
• Infection
• Injury to nerves or vessels
• Anesthetic/allergic reactions
• Elbow instability
• Joint stiffness
• Bone misalignment
• Persistence or recurrence of symptoms
• Re-rupture of the repaired tendon
• Hardware failure
• Need for additional surgery