Elbow interpositional arthroplasty

The goal of interposition arthroplasty is to relieve pain that occurs when bone surfaces rub together. To accomplish this, the ends of the bones are reshaped, and a small section of the patient's Achilles tendon or other soft tissue is fitted into the space between the joint surfaces. "It's like putting new tread on a tire," Dr. Hotchkiss says. Recovery time, including healing and rehabilitation can be up to four months.

Best candidates are cctive people with primary OA, posttraumatic OA or inflammatory arthritis who have too much damage for debridement but are too young for elbow joint replacement. "We might consider this surgery in a younger, relatively high-demand patient, such as a school teacher who can no longer write on the blackboard," Dr. Hotchkiss says, adding that candidates for the procedure also must have a stable elbow (with ligaments that aren’t too loose to hold the bones in place) with minimal bone loss.

Pros – Interposition arthroplasty can relieve severe pain while retaining some elbow function, and unlike an artificial joint, transplanted tissue won't loosen or dislocate. Bone stock is also preserved, which is crucial if elbow replacement is needed in the future. In Dr. Hotchkiss' experience, however, the results of the procedure have been long-lived: "We've done 20 or so [interposition arthroplasties] over Larsen class 3 [a 0 to 5 scale that grades disease severity] and none has had to go to total elbow replacement 15 years out."

Cons – The procedure doesn't completely relieve pain or restore full function and can’t be performed on some patients with severe disease.

Total elbow arthroplasty

Similar to hip or knee replacement, this surgery replaces damaged parts of the elbow with artificial components. Elbow implants may be linked, unlinked or linkable. A linked implant consists of two metal stems – one in the humerus and one in the ulna – joined by a cobalt-chrome hinge pin that articulates with the joint. In an unlinked prosthesis, the humeral and ulnar components aren't mechanically joined, relying instead on the surrounding tissue for joint stability. Newer linkable implants give the surgeon the option of leaving the implant linked or unlinked, depending on what's found during surgery. Average recovery time is a minimum of 12 weeks.

Best candidates were originally older, less active adults with end-stage inflammatory arthritis. However, elbow implants are now also used for OA and posttraumatic OA. Because they generally don't last more than a few years, they are not recommended for people less than age 60.

Pros – Elbow replacement can successfully relieve pain and restore lost motion and function in people with severely damaged and deformed joints.

Cons – The complication rate for elbow replacement is higher than for any other joint. Linked implants can ensure a stable elbow, even with severe bone loss, but tend to loosen and wear out quickly. Unlinked implants dislocate easily and for that reason are used less often. High overall failure rates – 25 percent fail at five to seven years – are due in part to poor tissue quality in the joint and, paradoxically, to the effects of better arthritis drugs.

"With the advent of DMARDs and biologics, we are presented with a new patient," Dr. Hotchkiss explains. "They are living longer, are more active and the adjacent joints are healthier. The elbow is just as arthritic and painful, but the wrist and shoulder are nearly normal, which means implants have to last much longer and are subjected to greater loads and strains."

Furthermore, there are few options when implants fail. "The ulna is a notoriously thin, narrow bone with a small diameter, so when an implant becomes loose, bone deficiency is a real problem. You can go from having an arm that can do light things quite well to one with no function at all," Dr. Hotchkiss says. "To be skeptical about elbow arthroplasty is a helpful and useful position."