Before seeing the patient, the therapist should obtain information concerning the general physical status of the patient and the level of activity prior to surgery to tailor the rehabilitation program to the individual capabilities and expectations. The function of the ipsilateral shoulder and wrist joints before the operation should be assessed, especially in the patient with rheumatoid arthritis in whom these joints may be involved. The status of the contralateral upper limb and the use of walking aids for lowerextremity pathology should also be investigated.

A thorough, detailed knowledge of the surgical technique, the type of implant used, complications encountered, and precautions prescribed by the treating surgeon are key to developing an effective rehabilitation program that will minimize impairment and maximize the patient’s functional ability. The therapist and the surgeon should maintain communication regarding the patient’s prognosis, treatment approach and guidelines, and progress.

The type of implant, linked or unlinked, is probably the single most important variable that influences the immediate postoperative regimen. The stability of unconstrained implants depends primarily on the integrity of the ligaments but may also be jeopardized by technical errors during prosthetic implantation or defects in the extensor mechanism. The therapist should know if an adequate reconstruction of the ligaments was achieved during surgery. The intraoperative range of motion after prosthetic implantation and the ligaments repaired should be recorded, and any tendency of the elbow to subluxate during passive range of motion, particularly in extension, should be noted and transmitted to the therapist. If the lateral collateral ligament has been released and repaired, it is necessary to unload it to allow adequate healing and avoid any disruption or elongation that may compromise stability. Therefore, the elbow of patients with unconstrained implants in whom the ligament has been released during surgery should be temporarily immobilized limiting full extension and supination (5,6).

The stability of semi-constrained implants is dependent on the loose hinge articulation between the ulnar and humeral components. The ligaments are routinely released during surgery, and no attempt at reconstruction is required (7). Postoperatively, the stability is not a concern and limiting motion to maintain stability is not necessary.

The surgical management of the triceps is an important factor that must be considered during the early rehabilitation program (Fig. 31-1). The surgical approaches that detach the triceps from its insertion, either by reflecting it to one side or by a split in the midline, require meticulous reattachment of the tendon through bone holes and protection of the repair postoperatively (8,9). Active extension of the elbow against gravity places stress on the repair and should be avoided during the first 3 to 4 weeks after surgery. When an approach that detaches the triceps is used,
only passive extension or gravity-assisted extension should be allowed. Some authors prefer an approach in which the triceps tendon is reflected from the muscle fibers as an inverted V and then the muscle fibers are released longitudinally (10). When this approach is used, the tendon is reattached to the muscle proximally allowing an V-Y plasty if flexion is limited intraoperatively. Healing of the musculotendinous junction is most important to achieve satisfactory muscle function, and the repair must be protected postoperatively to avoid disruption of the repair because this occasionally has been the cause of early posterior instability in unlinked implants (11,12). A period of 2 to 3 weeks of immobilization or controlled motion is required if this technique is used. Lastly, some arthroplasties may be implanted through an approach that preserves the triceps muscle and its attachment to the olecranon. This is the case in some posttraumatic situations or advanced rheumatoid elbows in which there is deficient distal humerus bone stock or the distal humerus is to be resected at the time of surgery. This approach works through the lateral and medial margins of the muscle (13, 14, 15). When this triceps-sparing approach is feasible, the postoperative regimen is greatly facilitated and active range of motion, including extension, can be initiated immediately after surgery.

The goals of rehabilitation after an elbow arthroplasty are to restore motion and strength, prevent complications of contracture and instability, and coordinate treatment of the involved tissues through the progressive stages of healing. Optimal rehabilitation requires careful timing and progression of therapy during the physiologic phases of tissue repair, balancing appropriate tissue stress to increase motion without provoking pain and inflammation (16). This requires the therapist to have a solid knowledge of the physiology of tissue healing and response to stress.

An informed patient is less likely to become anxious and will be more cooperative and involved in rehabilitation. Ideally, before the operation the therapist should give the patient an overview of the course of treatment and explain the importance of his or her efforts in reaching maximum potential. Preoperatively, the patient should be informed of the type of implant that is going to be used and its implications in the postoperative program. Additionally, the family setting of the patient and the facilities available to assist with home therapy should be investigated. Any concomitant pathology that may influence the therapy should be addressed with the patient before the operation. Detailed information of the limitations with the use of the arm during the early postoperative period should be given to the patient, and the therapy program should include a written outlined home program in addition to the therapy provided in the hospital. The patient should be aware of the meaning of passive, active-assisted, and active motion, and a basic knowledge about the use of splints is also desirable. All the time spent in the preoperative visit will result in higher benefit to the patient.

The rehabilitation starts at the time of surgery. If the inflammatory phase of healing can be minimized, more complete and rapid rehabilitation will be attained. Pain
can be a major limiting factor because it affects the patient’s effort and emotional well-being. The patient should be reassured that the pain is an expected part of the inflammatory response during the early phase of healing and should be encouraged to distinguish between tolerable discomfort and the type of pain that warns of impeding damage secondary to a complication of surgery.

The scheme represented by the mnemonic PRICEMM (protection, rest, ice, compression, elevation, medication, and modalities) is highly appropriate in the early postoperative period (17). Immobilization is recommended after an elbow replacement, but the type, optimal position, and duration of immobilization varies according to the implant design and the surgical approach. The aims of immobilization are to protect the healing structures, prevent injury, and maintain stability. Ice or cool packs are effective for reducing pain and edema and controlling hemorrhage and exudates in the inflammatory phase. The benefit of compression cryotherapy has been demonstrated in a prospective study in a group of patients using the Cryocuff (aircast), with significant reduction of postoperative pain, swelling, and blistering (17). Elevation may be the only edema control measure when a splint is in place. The patient should keep the elbow above the heart level whenever possible. When the patient is sleeping, the elbow is supported on pillows, and any discomfort secondary to shoulder pathology should be regularly checked.

The inflammatory process can also be controlled by pharmacologic methods. Nonsteroidal antiinflammatory medications may be used alone or in combination with narcotic drugs. Narcotic medications are rarely required for an extended period after elbow replacement, and whenever they are used, a strict control of the dose is recommended to avoid undesired side effects. When a continuous axillary brachial plexus catheter is placed postoperatively, the block should not be delivered until the patient is capable of cooperating with a neurologic examination to confirm the integrity of all three major nerves of the arm. In some instances, high-voltage galvanic stimulation has also proved helpful in controlling the inflammatory process by initiating involuntary muscle contractions that relieve edema (18). However, high-current intensity should be avoided when active or forceful muscle contraction is contraindicated, as when the triceps muscle has been disrupted or detached.

Functional joint range of motion and flexibility must be restored within the healing parameters of the structures involved. Early protective motion has been shown to provide benefits such as improved collagen organization and decreased pain perception (19). However, when rehabilitating an elbow replacement, the therapist should use different protocols according to the type of implant and the surgical approach. The ideal scenario for the therapist is when the extensor mechanism has been preserved and postoperative instability is not a concern. In this setting, which only occurs when a semi-constrained implant has been used with a triceps-sparing approach, active range of motion in every plane can be started immediately. On the other extreme is the patient with a resurfacing implant in whom the lateral collateral ligament has been repaired and the approach has also disrupted the triceps tendon. Under these circumstances, both triceps insufficiency and postoperative instability are a concern, and the therapist must proceed cautiously with range of motion. In between these extremes is a spectrum of risk that makes fluent communication between the surgeon and the therapist essential.