Like the quiet, cooperative child who receives less attention than her unruly sibling, the generally well functioning elbow may receive less attention than the aching back. But things are shifting for the humerus, ulna, and radius.
Delving into the Elbow
Dr. Ken Yamaguchi, the Sam and Marilyn Fox Distinguished Professor of Orthopaedic Surgery at Washington University School of Medicine in St. Louis, is part of the shift. “Elbow is one of the more exciting areas in orthopedics these days. Until relatively recently there was little known about it because there were fewer people working on elbow innovation as opposed to other body areas. Surgeons had also shied away from the elbow because they weren’t sufficiently familiar with the anatomy or procedures available. In the last 20-30 years, there has been strong leadership and mentoring by select people such as Bernard Morrey, Shawn O’Driscoll and Graham King, who produce a lot of research on the elbow…and they have inspired others.”
While the elbow used to be the bailiwick of general orthopedic surgeons, says Dr. Yamaguchi, patients are now demanding specialists. Dr. Yamaguchi, who has worked with Arthrex to develop an elbow arthroscopy instrumentation system, says,
There has been an exploding trend toward elbow arthroscopy in recent years. We’re learning more and more that many of the surgeries we did with large, open procedures were better performed arthroscopically. One of the areas growing in popularity is the arthroscopic treatment of elbow arthritis, a particular challenge because of the difficult anatomy and the small area that you have to operate in as compared to the knee or shoulder. The nerves and blood vessels are very close to sharp instruments so theoretically it is a more dangerous operation than other arthroscopies.
There are a maximum of opportunities in this minimally invasive realm, says Dr. Yamaguchi. “Most patients with elbow degenerative arthritis are not so bad that they need a joint replacement, but they’re not in good enough shape that no treatment is warranted. There are two growing areas of opportunity in elbow arthroscopy, one being to continue to develop and refine new techniques for existing indications of open surgery. The other, bigger opportunity is to disseminate information about elbow arthroscopy such that more people feel comfortable doing the procedure. More and more fellowships are giving trainees the opportunity to learn under the guidance of elbow athroscopists; AAOS has increasingly stepped up to the plate by offering related instructional courses. But those are only a start because elbow arthroscopy is not something that is easily aced by going to one or two courses.”
Dr. Yamaguchi, co-developer of The Tornier Latitude Total Elbow, notes, “The type of elbow arthritis we will need to treat in the future has changed. In the past, elbow joint replacements were commonly done for rheumatoid arthritis (RA) but that type of indication is far less common because the medications for RA are so effective. In contrast to RA, and just like all other joint replacement surgeries, the need for elbow replacement for degenerative arthritis will likely increase because the population is aging. These types of patients may require prostheses that have different attributes than the prosthetics that were effective for RA patients. The difference between degenerative arthritis and rheumatoid arthritis is that people with RA have low activity expectations because the disease affects many joints. Those young patients with degenerative arthritis, however, tend to be healthy overall and want to lead an active lifestyle. These more active people may require a more durable prosthesis than currently available.”
From the elbow rotation required in a curve ball to the rapid elbow extension in an overhead throw, there are any number of sports-related injuries that befall the elbow. Dr. Yamaguchi: “We now have more sophisticated treatments for the elbow that is injured in overhead throwing. We are learning about how to do ligament reconstructions with a ‘less is more’ approach. This involves smaller incisions, dissecting less and putting in ligament replacement or reconstructing grafts that replace the original ligament. The effect of this work is that players are getting back to the field, court, etc., faster.”
The Father of Elbow Treatments
If the elbow had a father, some say it would be Dr. Bernard Morrey, an orthopedic surgeon at Mayo Clinic in Minnesota. The creator of the first linked semi constrained artificial total elbow, Dr. Morrey continues to contribute to, and observe, the field: “At present the most exciting work coming out of our lab is the investigation into how host variation (genetic differences) may help explain why some patients react aggressively to trauma around the elbow. Some experience stiffness from minor injuries, while for others it takes a major trauma. We are in the preliminary stages now, and are developing animal models. Our hypothesis is that there will be genetic variations that explain the different levels of joint stiffness in elbow patients.”
Dr. Morrey, the co-developer of an external fixation system for traumatic elbow injury, continues, “Our clinical experience has shown that there is a wide range of ways that people react to the same surgery or the same injury. You can have 10 fractured elbows and get very different outcomes even though the treatments are all the same. It seems that different motion patterns also have something to do with the outcomes. If our hypotheses are true then we could potentially screen patients at risk for developing more extensive contractures. In the event that the animal models and experiments are successful, after we figure out who may be at risk, pharmacological solutions can be developed to prevent stiffness—or to treat the stiffness with medications rather than surgery. Other investigators are looking at biochemical and biological changes in stiff joints, but overall there is not a lot of research being done in this area.”
Dr. Morrey is pleased to see that a procedure popular for hips, knees, and other areas is increasingly being used to help those with elbow issues.
The use of arthroscopy is finally accepted as having value for a broad spectrum of elbow pathology, a change that has come about in the last 10 years. To a certain extent we are still getting a feel for the appropriate indications and the techniques that can be brought to bear on the elbow. The utility of arthroscopy in treating elbow problems is one of the great clinical changes in recent years, a change that will likely continue and flourish, especially with the increasing documentation of outcomes.
When asked what his non-elbow colleagues might not know about treating the humerus, radia, and ulna, Dr. Morrey says, “In general there is a lack of awareness of the progress that has been made in total elbow work. The perception is that elbow joint replacement is not successful, something that is patently untrue. We now have much better designs and techniques than we did 20 years ago. At Mayo over the last 25 years we have found that linked implants (where a mechanism mechanically locks two components together), is more successful than an unlinked implant. Because of that we feel that replacement is a viable concept. In the last decade orthopedic manufacturers have determined that they want an artificial elbow as part of their offerings…all of the major manufacturers have one in their toolboxes.”
As for what he would like to happen in the elbow realm going forward, Dr. Morrey states, “My number one goal would be that orthopedists step back and focus on better management of acute elbow fractures. We have evidence showing that when we try to salvage or revive an injured elbow, the outcome of the initial treatment, if done right, is always better than the outcome of the reconstruction. Secondly, I would like to see an enhanced awareness of the indications and outcomes for interventions by the orthopedic community. And finally, I would hope that more orthopedic surgeons could understand and possess the competence to execute these treatments.”
Take note, medical students. An old field is new again.
