Dr Gautam Tawari is the best elbow surgeon in Mumbai, India. He has worked and trained with UK’s best elbow surgeons and specialises in elbow surgeries. He has proficiently performed all kinds of simple & complex Elbow Surgery. 

He undertakes elbow surgery like Elbow Replacements, Elbow Arthroscopies, treatment of Elbow fractures  & sports Injuries around the elbow.

Elbow joint is a complex joint and hence elbow surgery is considered as one of the most technically demanding and challenging surgery. Surgical accuracy and caution is paramount whilst undertaking elbow surgeries.    

 

Common Elbow Problems and Related Information

Elbow SurgeryElbow Instability
In elbow joint, primary stability is contributed by medial & lateral collateral ligament. The medial collateral ligament (MCL) has three elements the anterior band (which is most important for stability), posterior band and transverse band. The lateral ulna collateral (LUCL) consists of interlacing fibres at different angles and provides dynamic stability to the joint.

Types of Instability
Acute – A traumatic episode disrupts one or more of the elements contributing to stability by placing abnormal forces on to a normal elbow
Chronic/Recurrent – as a result of previous injury one or more of the stabilising elements is deficient and normal forces applied to the abnormal elbow can result in repeated dislocation or subluxation of the elbow.

Treatment
In acute cases, surgery is required to repair anatomical structures to permit active mobilisation of the elbow within a week of the injury if possible.  The aim of surgery is to restore and maintain normal articular alignment. 

In chronic/recurrent cases, reconstruction of LUCL followed by MCL (if required) is undertaken using either autologous graft (triceps, hamstring or palmaris graft) or artificial ligament (LARS ligament).

Recovery
Active elbow mobilisation is commenced as soon as possible. Stability is improved by undertaking a protocol based phased physiotherapy programme. Return to activities is generally at 4-8 weeks and return to sports at about 3-4 months.

Elbow SurgeryDistal Biceps Rupture
The biceps is a large muscle in the front of the upper arm. It is attached at the top in the shoulder and beyond the elbow into the radius bone by a strong tendon. This strong tendon at the elbow can rupture with a forced contraction of the biceps muscle. It is felt as a pop in the elbow with accompanying pain.

Males over the age of 35 years, strength athletes, bodybuilders or heavy manual workers, are most likely to get a biceps tendon rupture.

Presentation
After the injury there is usually localised pain at the front of the elbow, with bruising and swelling. The biceps muscle may retract up the upper arm crating a prominent bump which is often visibly different to the other biceps when contracting the muscle.

Treatment
Surgery is the mainstay of treatment. A small (percutaneous) approach, reattaching the tendon down to the bone is used. The repair is strong and patients can start moving soon after the surgery in a hinged elbow brace. However lifting must be avoided for at least 6 – 12 weeks weeks after surgery.

Chronic ruptures/delayed presentation
A biceps tendon rupture that is over 4 weeks old is often more difficult to repair directly. The tendon is retracted up the arm and stuck, so a second higher incision may be made to retrieve it. Sometimes a reconstruction with another tendon might also be required.

Elbow SurgeryTriceps Tendon Rupture
The triceps is the muscle at the back of the elbow . Traumatic distal triceps avulsion is rare and occurs most commonly in contact sports. 

Presentation
A history of pain, swelling and bruising at the back of the elbow after a forced flexion in an extended elbow would raise the possibility of triceps avulsion. The strength of elbow extension should be assessed while the examiner feels the tendon for a defect.

Treatment
Surgery is the mainstay of treatment. Anatomical footprint repair for acute ruptures (within three weeks of injury) with transosseous sutures or suture anchors is commonly utilised. For delayed ruptures hamstring grafts taken from the patients own thigh or donor grafts can be used. 

Recovery
The elbow is rested in extension splint for 2 weeks and then gradual flexion is allowed. Strength training is started at 6 – 12 weeks.

Elbow SurgeryTennis Elbow
Tennis elbow is a chronic degenerative condition of the tendon on the outside of the elbow. It is also known as ‘lateral epicondylitis’.

Cause
Extensor Carpi Radialis (ECRB) tendon is most commonly affected, and it is usually precipitated by repetitive strain. This tendon is involved in extending the wrist joint and is also active when gripping with the wrist extended (as in tennis). Any activity that twists and extends the wrist can lead to tennis elbow.

Presentation
Tenderness and pain when pressure is applied to the outside of the elbow. Pain when the wrist or hand is straightened (wrist extension) or when lifting a heavy object.
Pain is typically localised over the bony bump on the outside of the elbow (lateral epicondyle) and may extend down to the hand. This area is usually very tender to touch.

Treatment
The type and duration of the treatment depends on the severity of the condition

  • Elimination of the activities that cause the pain (tennis, golf, Gym)
  • Pain killers medications relieve the pain.
  • A tennis elbow clasp can be worn just below the elbow to limit the stress on the ECRB tendon.
  • Physiotherapy focussed on the eccentric exercises helps to release the tendon inflammation and retrain the muscles.
  • Injections are second line of treatment. Steroid injections should be avoided, they have a detrimental overall effect on the tendon.
  • More recentlyPlatelet Rich Plasma (PRP) injections have shown to be more effective than steroid injections, but are more expensive.

Surgery
For very severe cases and those that fail to improve after injections surgery may be necessary. The surgery is usually performed as day case surgery. This may be performed by an open approach, percutaneous or arthroscopically (keyhole).

Prevention
To prevent tennis elbow from reoccurring, it is important to make sure the muscles are kept strong by exercise, warming up before starting to use the muscle may also help to prevent the condition.

Elbow SurgeryGolfers Elbow
Golfer’s elbow is a chronic degeneration of tendon on the inner side of the elbow. It is also known as ‘medial epicondylitis’ 

Cause
The exact cause of golfers elbow is not known, but it does tend to occur after repetitive strain of the tendon or injury.

Presentation

Pain over the bony prominence on the inner side of the elbow. The pain often extends down the forearm to the wrist and hand. The pain is made worse on loading of the flexor-pronator muscles of the forearm.

Treatment 
The type and duration of the treatment often depends on the severity of the condition.

  • Elimination of the activities that cause the pain (tennis, golf, Gym).
  • Pain killers and anti-inflammatory medications
  • An elbow worn just below the elbow to limit the stress on the muscles helps in initial treatment.
  • Physiotherapy focussed on the eccentric exercises helps to release the tendon inflammation and retrain the muscles
  • Injections are second line of treatment. Steroid injections should be avoided, they have a detrimental overall effect on the tendon.
  • More recently Platelet Rich Plasma (PRP) injections have shown to be more effective than steroid injections, but are more expensive.

If the condition does not respond to the above treatments, surgery may be necessary.
The surgery is usually performed as day case surgery. This may be performed by an open approach, percutaneous or arthroscopically (keyhole).

Prevention 
To prevent golfers elbow from reoccurring, it is important to make sure you keep the muscles strong by exercise, warming up before starting to use the muscle also helps to prevent the condition.

Elbow SurgeryElbow Replacement
Elbow joint replacement, also referred to as Total Elbow Arthroplasty(TEA) is an operative procedure to treat the symptoms of arthritis that have not responded to non-surgical treatments.

Indications
Elbow Joint Replacement surgery is recommended in following common conditions:

  • Severe Elbow Arthritis
  • Complex elbow trauma resulting in a complex elbow fracture in older patients with osteoporosis
  • Tumour or growth in the elbow joint
  • Rheumatoid Arthritis
  • Inflammatory disease of the elbow

Surgical Procedure
The goal of elbow joint replacement surgery is to eliminate pain and increase the mobility of the elbow joint. The surgery is performed under a general anesthesia.
An incision is made over the back of the elbow. The muscles and tendons and ligaments are moved away to expose the elbow joint. Care is taken to move the ulnar nerve to prevent nerve damage. The damaged joint surfaces of the humerus, radius and ulna are cut and the bones are hollowed out from the inside. Proper fit of the prosthesis is obtained and the prosthesis is cemented.
Proper movement of the hinge joint is confirmed and the joint is tested through its range of motion. The skin is closed and the elbow is then dressed and bandaged. 

Recovery
An average hospital stay is 3-4 days. Pain is controlled with PCA (patient controlled analgesia) , this allows the patient to push a button to deliver a dose of pain medicine. Surgical wound takes 10-14 days to heal. 
Physiotherapy begins 3-4 days after the surgery and continue for about 6 weeks to 12 weeks to regain full range of motion of the elbow joint.

Elbow SurgeryElbow Fractures 
Elbow joint is made of three bones, the humerus, radius and ulna.
Elbow fractures occur from trauma like a fall on an outstretched arm, a direct blow to the elbow, or an abnormal twist to the joint beyond its functional limit.

Types

  • Radial head and neck fractures: Fractures in the head portion of the radius bone are referred to as radial head and neck fractures.
  • Olecranon fractures: These are the most common elbow fractures, occurring at the bony prominence of the ulna.
  • Distal humerus fractures: These fractures are common in children and elderly people. Nerves and arteries in the joint may sometimes be injured in these fractures.

Presentation
Usual presentation includes pain, bruising, stiffness, swelling around the elbow, a popping or cracking sound, numbness or weakness in the arm, wrist and hand, and deformity of the elbow bones.
An X-rays of the joint or/and a CT scan is needed to determine the extent of the injury to the elbow joint and allows surgical planning.

Treatment
Surgery is indicated in displaced and open fractures to realign the bones and stabilise the joint with screws, plates, pins and wires.
Surgical treatment is aimed at maximizing early motion and to reduce the risk of stiffness. Strengthening exercises are recommended to improve the range of motion.

Elbow SurgeryElbow Arthroscopy
The elbow joint is a hinged joint where the upper arm bone (humerus) meets the two forearm bones (ulna and radius). The unique anatomy of the elbow joint allows it to pass through a broad range of motion. The elbow experiences tremendous stress during repetitive overhead and lifting activities/sports. This may lead to the formation of small loose fragments of cartilage or bone (loose bodies) or elbow joint spurs.

Arthroscopic surgery of the elbow is challenging because of the joint’s anatomy. The bones lie close together, and nerves and blood vessels are located very close to the joint. Although it is a difficult procedure, arthroscopic surgery is often the ideal choice for treating certain elbow conditions. An experienced elbow arthroscopic surgeon can safely navigate through the joint to get the desired results.

An injury or arthritis can damage the ends of the bones and cause bone spurs to develop. These spurs can be painful and make it hard to move the elbow. This extra bone, loose bodies can be removed by using special tools, such as a burr, inserted into the joint through the portals or small incisions. After the spurs are removed, the elbow moves more easily and with less pain.

Conditions like Tennis elbow, OK procedures, Complex fracture fixation can also be undertaken using arthroscopic techniques.

Operative Procedure Details
An elbow arthroscopy introduces an arthroscope (small ‘telescope’) into the elbow joint through several small 2-3 millimeter incisions.
The arthroscope is used to identify the location of the loose bodies and the spurs.
The loose bodies can be removed by using specially designed small grasping instruments. The bone spurs can be removed by visualising the spur with the arthroscope and using a small burr to remove the spur.
These elbow arthroscopic procedures take about 30-90 minutes and are done as a day-case procedure.

Elbow SurgeryElbow Stiffness
The elbow joint is a type of hinge joint. The normal range of bending (flexion) and straightening (extension) is from 0 to 145 degrees, although the range of motion that we work within for daily activities is only from 30 to 130 degrees (functional range). Loss of extension is usually less disabling than loss of same degree of flexion.

Causes
Intrinsic / Intra-articular Causes (within elbow joint)

  1. Post-traumatic Osteoarthritis
  2. Primary Osteoarthritis
  3. Rheumatoid
  4. Joint Infection
  5. Malunions

Extrinsic / Extra-articular Causes (outside elbow joint)

  1. Burns
  2. Heterotopic Ossification
  3. Congenital – arthrogryposis, congenital disloc radial head

The commonest cause of stiffness is after trauma and injury. In fact, some stiffness after an elbow injury is very common. The amount of stiffness is directly related to the degree of initial trauma and the degree of involvement of the joint surfaces.

The ‘Simple’ Stiff Elbow is one that recovers well. The criteria are:

  • Mild to moderate contracture (<80)
  • No or minimal prior surgery
  • No prior ulnar nerve transposition
  • No or minimal internal fixation in place
  • No or minimal heterotopic ossification (bone in the muscles)
  • Normal bony anatomy has been preserved

Treatment
The aim is to give the patient pain-free, functional and stable elbow. This means 30-130 degrees flexion and 100 degrees of rotation.

Physiotherapy involves active motion exercises. Ideally this should be with a physiotherapist who has an interest in upper limb rehabilitation.  Close consultation with the surgeon is recommended. 

Surgery is indicated when patients are no longer improving in their original posttraumatic rehabilitation program. At least 6 to 9 months should be allowed for the inflammatory phase of soft tissue healing to resolve.
Arthroscopic release is ideal for stiffness due to arthritis and when there has been no previous surgery. However, if there has been a previous internal fixation and there are extrinsic causes for the stiffness open surgery may be required