Elbow open debridement (elbow arthritis)

The elbow is a hinge joint that connects the humerus (upper arm bone) to the radius and ulna (forearm bones). The joint allows flexion (bending the elbow) and extension (straightening the elbow) movements as well as supination and pronation (turning your palm up and down).

The elbow is made up of three bones and a multitude of soft tissue structures that are important for the stability, movement and function of the elbow.

Like every other joint in the body, the elbow joint can be subjected to arthritis. Elbow arthritis can be caused by rheumatoid arthritis, elbow trauma and normal age-related changes (primary elbow arthritis) among other less common conditions.

Primary elbow osteoarthritis represents 1 to 2% of all elbow arthritis, with the majority of cases of symptomatic elbow arthritis coming from trauma or rheumatoid arthritis. Elbow arthritis tends to involve three main processes.

Firstly, the breakdown of the cartilage, followed by the development of osteophytes, bony growths or bone spurs that can develop in joints as the joint attempts to heal itself. Finally, progressive joint capsular contracture ensues.

Advanced arthritis then leads to destruction of the joint space, which can result in a number of potential symptoms:

• Pain
• Stiffness
• Swelling
• Tenderness
• Limited range of movement
• A feeling of catching and grinding

Diagnosing elbow arthritis can be achieved a number of ways. It may be possible to diagnose through a full history taking and physical examination by a doctor or physiotherapist. It might also be necessary to have imaging, such as an X-rays or a CT scans.

There are a number of different treatments available for elbow arthritis including medication, activity modification, physiotherapy exercises, hot/cold therapy and corticosteroid injections.

However, if the pain and limitation in function becomes severe enough surgery can be necessary. Total elbow replacement surgery is usually avoided unless in elderly patients with severe pain and functional restriction due to the likelihood of component loosening and the need for revision surgery.

Prior to having an open elbow debridement you will have a pre-operative assessment before your surgery. This will allow you to discuss any questions you may have and to find out more about the surgery.

Open elbow debridement surgery is performed under general or regional anaesthetic as day surgery, meaning you will usually be operated on and released on the same day. Usually a nerve block will be administered in order to reduce the feeling in your elbow.

The surgery is performed as an open procedure, rather than arthroscopically, requiring an incision approximately 7-10cm long on the back of your elbow. The triceps muscles are then split and important structures such as the ulnar nerve are preserved.

The surgeon will then remove excess soft tissue, bone or osteophytes from the joint in order to allow improved function. At the end of the surgery the structure will be preserved and closed using dissolvable sutures. After the operation you will return to the ward wearing a collar and cuff until the nerve block wears off. You will have a soft bandage around your elbow.

Shoulder and elbow surgery can result in considerable pain and discomfort after the operation. Traditional painkillers are not always effective and have side effects. We usually offer you a local anaesthetic “block” to reduce the pain and discomfort following the procedure and also allow early more comfortable physiotherapy (if required). This consists of an injection at the side of your neck onto the nerves that supply your shoulder. The injection itself is fairly painless.

When is anaesthetic given?

The procedure is carried out before the start of your operation. You will have a small plastic tube placed in your arm (drip). Then you may have some sedation to make you feel relaxed. A small numbing injection in the skin is placed prior to the block needle (which is smaller than a blood-taking needle). Your arm will then start to feel very heavy and numb (a similar sensation to when you have been lying on it). This spreads down the outside of the arm (and spares the inside).

Surgery is then carried out under sedation (you are comfortable, relaxed and either awake or sleeping if you prefer) or occasionally under general anaesthesia (you are unconscious and unaware). If you are awake, you are welcome to watch the procedure on a TV screen, and we will explain to you what is happening. If you require any extra pain relief during the procedure, we can easily give you this through your drip. The block will reduce the overall amount of painkilling drugs that you will require during and after the operation.

How long does it take for anaesthesia to wear off?ation

The numbness will usually last for between 8 and 24 hours (depending on anaesthetic mixture used). We will leave your arm in a sling; please protect your arm whilst it is numb.

You will initially experience some ‘pins and needles’ as the block wears off and then some pain. Please prepare for this by taking the painkillers that we provide. Start these before the block wears off and expect to need them regularly for around 48hrs.

Occasionally we may recommend that at the time of the block we also place a small tube (catheter) that is fixed in place and through which we can give you further local anaesthetic to prolong your numbness for a few days. We would recommend this in situations where your pain after the operation is likely to be severe.

Complications of anaesthesia

Anaesthesia is fairly safe for most people. If your health is not good the risks may be increased. Commoner complications include nausea and sore throat.

Local anaesthetic nerve blocks are generally considered to be safe. There is an approximately 5% (1 in 20) chance that they will fail or not work as well as expected. They tend to cause a small pupil and droopy eyelid temporarily and you may notice a hoarse voice or slight breathlessness.

Rare complications include reactions to the local anaesthetic solutions and nerve injury (the risk of temporary nerve symptoms e.g. tingling, numbness or weakness for a limited period is around 1 in 100 blocks and the overall risk of permanent injury approximately 1 in 5,000- 10,000 injections).

Analgesics (painkillers)

Paracetamol and an anti-inflammatory drug (if suitable for you – usually ibuprofen or diclofenac) are often used in combination. Take these regularly for the first few days.

Stronger painkillers:

Your anaesthetist will talk to you about strong painkillers, usually codeine, tramadol, oxycodone or morphine. Take these if your pain is poorly controlled (instructions will be on the packet). Some patients experience light-headedness when taking stronger painkillers; so be careful especially at first (rest up after taking them, don’t carry hot drinks or anything sharp) and take them only to counteract severe discomfort. Nausea and constipation can also occur, so drink plenty of water and increase the fibre in your diet; occasionally laxatives may be required (available from chemists).

Discharge

If you are discharged on the same day as your operation, there should be someone keeping an eye on you during the first 24 hr period. If the painkillers make you excessively drowsy, then your carer needs to rouse you and ensure you not too sensitive to them.

Emergency contact numbers will be available on your discharge information if you or your carer wishes to talk to a trained member of staff.

The risks of open elbow debridement replacement surgery will be discussed with you in detail at your pre-admission clinic appointment. Risk factors for open elbow debridement surgery which can affect a very small percentage of patients include:

• Infection: The risk of infection is increased with open elbow debridement surgery compared to arthroscopic procedures due to it being an open surgery, however infection is very rare. Our theatres use industry standard ultra-high flow air systems which results in highly filtered and very rapid changes in air pressure ensuring the environment is as clean as possible. We also have fixed antibiotic treatment protocols drawn up by microbiologists to help reduce the risk of infection.
  
  
• Nerve injury/damage: There is a small risk of nerve injury or damage during elbow surgery as the surgeon is operating so close to the nerves. They know where they are and make every effort to avoid injuring or damaging the nerves but it is important to understand there is a small risk and the damage can be permanent.
  
  
• Stiffness: there is a risk of stiffness following your open elbow debridement surgery.
  
  
• Pain: Initially following your open elbow debridement surgery you will feel some pain. This is a natural part of the healing process. We will help you to manage this with medication and advice. The pain will generally subside with time and recovery.
  
  
• Thrombosis/blood clot: There is a small risk of thrombosis or blood clotting following your surgery. In this case you may be given compression sleeves in order to improve circulation and reduce the risk.
  
  
• Failure to relieve symptoms: There is a very small chance that the surgery will not relieve your symptoms.

Once the effects of the anaesthetic and nerve block have worn off pain killers will be used to control your pain. The arm should be elevated as much as possible for the first few days to prevent the hand and fingers swelling. The dressing will be removed soon after your operation. The wound is cleaned and redressed with a simple dressing.

You should notice an improvement in symptoms within a few weeks but full recovery can take up to 3-6 months. Avoid forced gripping or heavy lifting for 2-3 weeks.

In order to return to driving, your hand needs to have full control of the steering wheel and if your left arm was operated on then also the gear stick. In terms of returning to work it will depend on your work environment.

Returning to heavy manual labour should be prevented for approximately 4-6 weeks. Early return to heavy work may cause problems with your recovery. You will be given advice on your own particular situation.

You will be reviewed by your consultant approximately 6-8 weeks after your surgery. Immediately after your surgery you will be referred for outpatient physiotherapy. You will follow a regimented physiotherapy programme that will allow you to start to regain movement in your elbow and then strengthen the muscles in order to return to all of your normal activities as follows:

• 0-3 weeks: Surgical site protection, ice, compression, elevation, pain relief, passive and gentle elbow range of movement exercises, maintenance exercises for the wrist and hand.
• 3-6 weeks: Progression to active range of movement exercises, gentle isometric strengthening exercises, gentle gripping and squeezing exercises.
• 6-12 weeks: Continued range of movement and stretching exercises, emphasis on strengthening exercises for the elbow and progressive resistance exercises, function activities including those related to work or leisure activities that you are aiming to return to.