EDU: Surgery: Elbow Fusion

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Here's an article on " Elbow Fusion's " for anyone who might be interested.

If you like the article you might want to check the site out at

http://www.handuniversity.com/topics.asp?Topic_ID=7 (copy and paste) to see

the illustrations of an elbow and links to many illustrations which might

give you a better understanding of the procedure.

Marilyn

A Patient's Guide to Elbow Fusion

Introduction

Arthritis of elbow has many causes, and there are many ways of treating the

pain. These treatments can be very successful, at least for awhile. But

eventually the elbow can become so painful that conservative treatments

don't work anymore. At this point, your doctor may recommend surgery to fuse

the elbow. Elbow fusion may also be necessary after severe trauma to the

elbow. Fusion surgery is sometimes called arthrodesis.

This document will help you understand

• how an elbow fusion eases the pain of arthritis

• how the operation is done

• what the recovery process is like

Anatomy

How does the elbow work?

The elbow joint is made up of three bones: the humerus bone of the upper

arm, and the ulna and radius bones of the forearm.

The ulna and the humerus bones meet at the elbow to form a hinge. This hinge

allows the arm to bend and straighten.

The connection of the radius to the humerus allows rotation of the forearm.

The upper end of the radius is round. It turns against the ulna and the

humerus as the forearm and hand turn from palm down (pronation) to palm up

(supination).

Articular cartilage is the smooth, rubbery material that covers the bone

surfaces in most joints. It protects the bone ends from friction when they

rub together as the joint moves. Articular cartilage also acts sort of like

a shock absorber. Damage to the articular cartilage eventually leads to

degenerative arthritis.

When the articular cartilage is worn away over time, the bones begin to rub

against each other. This causes the pain of degenerative arthritis.

Degenerative arthritis is also called osteoarthritis.

Document Link: A Patient's Guide to Osteoarthritis of the Elbow Joint

Rationale

Why do I need elbow fusion surgery?

A fusion of any joint eliminates pain by making the bones of the joint grow

together, or fuse, into one solid bone. Fusions are used in many joints.

They were very common before the invention of artificial joints. Fusions are

still performed fairly often to treat arthritis pain. An elbow fusion gets

rid of pain because the bones of the joint no longer rub together.

Advanced arthritis can change the alignment of the elbow, leading to

deformity. Fusing the bones together improves the alignment and prevents

further deformation. Fusion may also be needed to align the elbow after a

severe injury.

You will not be able to bend your elbow after fusion surgery. An elbow

fusion is a tradeoff. You will lose the hinge motion in your elbow, but you

will regain a strong, pain-free elbow joint. Regaining strength is

especially important to laborers who work with their arms and hands. Some

patients may need range of motion more than strength. In these cases,

doctors usually recommend surgeries such as interposition arthroplasty or

elbow joint replacement.

Document Link: A Patient's Guide to Interposition Arthroplasty

Document Link: A Patient's Guide to Elbow Joint Replacement

The radius bone of the forearm is usually not part of the elbow fusion. The

end of the radius forms a joint with the ulna. This joint allows you to

pronate and supinate (rotate) your forearm and hand. When this joint is a

source of pain, the surgeon may remove the round end of the radius near the

elbow. This still allows the forearm to rotate.

Pre-intervention Instructions

What do I need to do before surgery?

The decision to proceed with surgery must be made jointly by you and your

doctor. You need to understand as much about the procedure as possible. If

you have concerns or questions, you should talk to your doctor.

Once you decide on surgery, you need to take several steps. Your surgeon may

suggest a complete physical examination by your regular doctor. This exam

helps ensure that you are in the best possible condition to undergo the

operation.

On the day of your surgery, you will probably be admitted to the hospital

early in the morning. You shouldn't eat or drink anything after midnight the

night before. The amount of time patients spend in the hospital varies. It

will depend a lot on you.

Procedure

What happens during elbow fusion surgery?

There are many different types of operations to fuse the elbow. Most of the

procedures are designed to remove the articular cartilage from the joint

surfaces of the hinge joint and then bind the two surfaces together until

they heal. When two raw bone surfaces are held together like this, your body

treats them like a broken bone. New bone forms to heal the two pieces

together. When the fusion is healed, a strong, solid connection between the

humerus and ulna will have replaced the painful arthritic joint.

Surgeons do elbow fusion operations in different ways. Many use a bone

graft. A bone graft involves taking bone tissue from one area and

transplanting it into another area. This encourages the ends of the bones to

grow together. In most cases the graft is taken from the pelvis, or hipbone.

If your doctor grafts bone from your pelvis, you will have two

incisions--one on the back of your elbow, and one on the side of your hip.

The first step in an elbow fusion is an incision down the back of the elbow.

The incision is made on the back side because most of the blood vessels and

nerves are on the inside of the elbow. Entering through the back of the

elbow makes them less likely to be damaged.

The surgeon then moves the tendons and ligaments to the side to expose the

joint surfaces. Care must be taken to protect the nerves that run beside the

elbow joint on their way to the hand. The surgeon then removes the articular

cartilage surface of each side of the joint.

The surgeon must then fix the humerus and ulna in place until they can heal

together. The elbow is bent to ninety degrees and the bones are carefully

aligned. The bones must be properly aligned and immobilized for fusion to

occur.

There are different ways of holding the bones together. Many surgeons place

a metal plate with screw holes on the back of the elbow, from the humerus to

the ulna. The metal plate is attached to the bone with metal screws. The

metal plate stays in the arm permanently. It is only removed if it causes

problems.

Another way to hold the bones together is to use an external fixator. An

external fixator involves placing metal pins through the bones above and

below the elbow joint. Your surgeon may also place a metal screw inside the

ulna and humerus to pull the bones together. The external fixator device is

then placed on the elbow outside the skin, after the incision is sewn up.

The external fixator attaches to the metal pins, which come through the

skin, with metal rods and bolts. Doctors sometimes choose an external

fixator if there have been problems with an infection in the elbow joint.

At the end of the fusion operation, the incisions are sutured together. As

long as you don't have an external fixator, the arm is placed in a large

splint or cast. It usually takes about twelve weeks for the fusion to become

solid. At this point the metal pins and rods of the external fixator are

removed.

Complications

Does elbow fusion surgery cause any problems?

As with all major surgical procedures, complications can occur. This is not

intended to be a complete list of complications.

Some of the most common complications following elbow fusion surgery are:

• Infection

• Nerve or blood vessel injury

• Non-union

Infection

Any surgery carries the risk of infection. You will probably be given

antibiotics before the procedure to reduce the risk. If you get an

infection, you will need more antibiotics. If the area around the bone graft

and metal plate becomes infected, you may need surgery to drain the

infection.

Nerve or Blood Vessel Injury

All of the nerves and blood vessels that go to the forearm and hand travel

across the elbow joint. Because the operation is performed so close to these

nerves and vessels, it is possible to injure them during surgery. When the

damage is caused by retractors used during surgery to stretch them out of

the way, the nerve symptoms are usually temporary. Permanent injury to the

nerves or blood vessels rarely happens, but it is possible.

Non-union

Sometimes the bones do not fuse as planned. This is called a non-union, or

pseudarthrosis. (The term " pseudarthrosis " means " false joint. " ) If joint

motion from a non-union continues to cause pain, you may need a second

operation. In the second procedure, the surgeon usually adds more bone graft

and checks that the plates and screws are holding the bones solidly in

place. The bones need to be completely immobilized for fusion to occur.

Post-operative Instructions

What can I expect after surgery?

After surgery, you will either wear an external fixator for up to twelve

weeks or a long-arm cast for about six weeks. Both devices hold the elbow

still while the ends of the bones fuse together. Your surgeon will want to

check your elbow within five to seven days. Stitches will be removed after

ten to fourteen days, although most of them will have been absorbed by your

body. You may have some discomfort after surgery. Your doctor can give you

pain medicine to control the discomfort.

You should keep your arm elevated above the level of your heart for several

days to avoid swelling and throbbing. Keep it propped up on a stack of

pillows when sleeping or sitting.

Rehabilitation

What will my recovery be like?

Patients who have an external fixator should expect to wear it for up to

twelve weeks. When a cast is used, some doctors will replace it with a

removable splint after six to eight weeks. If you wear a cast, the joints in

your wrist and fingers may feel stiff or sore.

Your surgeon will X-ray your elbow several times after surgery to make sure

that the bones are healing properly. Once your surgeon is sure that fusion

has occurred, you can safely begin a strengthening program. It will take

some time to regain the strength in your arm. As with any surgery, you need

to avoid doing too much, too quickly.

If you keep having pain or find that you have stiffness in the shoulder,

wrist, or finger joints, you may need a physical or occupational therapist

to direct your recovery program. The first few therapy treatments will focus

on controlling the pain and swelling. Your therapist may use gentle massage

and other types of hands-on treatments to ease muscle spasm and pain. Then

you'll begin gentle range-of-motion exercises for the arm.

Strengthening exercises give you added stability around the elbow joint.

Some of the exercises you'll do are designed get your arm working in ways

that are similar to your work tasks and daily activities. Your therapist

will teach you ways to use your arm so that you can do your tasks safely and

with the least amount of stress on your elbow. Before your therapy sessions

end, your therapist will teach you a number of ways to avoid future

problems.

Your therapist's goal is to help you keep your pain under control, improve

your strength, and learn how to adjust your activities to avoid putting too

much strain on your arm and elbow. When you are well under way, your regular

visits to the therapist's office will end. Your therapist will continue to

be a resource, but you'll be in charge of doing your exercises as part of an

ongoing home program.

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