Artroplastia de codo

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview¶

• Continued advances in exposure, implant design, and complication management are key to making elbow arthroplasty as reliable and lasting as hip or knee arthroplasty [1].
• The continued success of total elbow arthroplasty will depend on advances in surgical planning, technique, implant design, and materials [2].
• Patients undergoing elective total elbow arthroplasty have slightly higher complication rates than those undergoing shoulder, hip, or knee arthroplasty [4].
• The range of indications for total elbow arthroplasty is broadening [15].
• Total elbow arthroplasty for acute trauma and osteoarthritis is becoming increasingly more common [15].
• Total elbow arthroplasty is a surgical option for end-stage elbow arthritis [37].
• Indications for total elbow arthroplasty are expanding from rheumatoid arthritis to osteoarthritis, post-traumatic arthritis, and acute fractures [37].
• The complication and revision rates for joint replacement surgery for elbow tumours are comparable to other indications for elbow replacement surgery [7].
• Survival rates for the Latitude primary total elbow arthroplasty remain low [25].
• Complication rates for the Latitude primary total elbow arthroplasty remain high [25].
• Complication rates for the Latitude primary total elbow arthroplasty are comparable to those of other elbow arthroplasties [25].
• Lateral resurfacing elbow arthroplasty is a satisfactory alternative to total elbow arthroplasty [16].
• Lateral resurfacing elbow arthroplasty has lower rates of complications than total elbow arthroplasty [16].
• Lateral resurfacing elbow arthroplasty does not require activities to be restricted to the same extent as total elbow arthroplasty [16].
• With careful patient selection, convertible total elbow arthroplasty provides patients with good to excellent outcomes [17].
• With careful patient selection, convertible total elbow arthroplasty provides patients with substantial improvements in the range of movements [17].
• Functional improvement is possible by means of total elbow replacement when proper indications are satisfied [22].
• Proper indications for total elbow replacement include patient understanding of risks and ability to comply with postoperative rehabilitation [22].

Anatomy & Pathophysiology¶

Bony Anatomy¶

• The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that provide bony stability [55].
• The ulnohumeral joint is formed by the articulation of the trochlea with the ulna within the greater sigmoid notch [55].
• The ulnohumeral articulation provides highly congruent anatomy through almost 180° of articular contact, except for a bare area of the greater sigmoid notch devoid of cartilage [55].
• The radiocapitellar joint is formed by the capitellum and the radial head [55].
• The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [55].
• The radial head articulates with both the capitellum and the lesser sigmoid notch of the ulna [55].
• The proximal radioulnar joint holds the radius in close approximation to the ulna via the annular ligament [55].
• The distal humeral articulation is angled 30° from the longitudinal axis of the humerus [55].
• The axis of rotation of the distal humerus is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side more distal than the lateral side [55].
• The ulna bends approximately 8° medially at 8 cm from the tip of the olecranon [55].
• The articulation to the tip of the coronoid process is approximately 30° from the long axis of the ulna in the sagittal plane [55].
• The trochlea has a 300-degree arc of cartilage [61].
• The medial column of the distal humerus diverges from the humeral shaft at a 45-degree angle [61].
• The lateral column of the distal humerus diverges from the humeral shaft at a 20-degree angle [61].
• The articular surface of the distal humerus is angled 30 degrees anterior to the humeral shaft axis [59, 60].
• The distal humerus consists of medial and lateral columns [59, 60].

Ligamentous Anatomy & Stability¶

• Elbow stability is conferred by bony articular anatomy and ligamentous structures on the medial and lateral sides [28].
• The primary stabilizers of the elbow are the ulnohumeral articulation, the medial ulnar collateral ligament (MUCL), and the lateral ulnar collateral ligament (LUCL) complex [28].
• The secondary stabilizers of the elbow are the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [28].
• The MUCL is comprised of the anterior bundle, posterior bundle, and transverse ligament [53].
• The anterior bundle of the MUCL is the strongest component and the primary restraint to valgus stress within functional elbow range of motion [53, 59, 60].
• The anterior bundle of the MUCL is further subdivided into anterior and posterior bands, with the anterior band tight in extension and the posterior band tight in flexion [53].
• The posterior bundle of the MUCL is the primary restraint to valgus stress with the elbow in maximal flexion [59, 60].
• The MUCL originates on the posterior medial epicondyle and inserts on the sublime tubercle of the medial coronoid process [59, 60].
• The sublime tubercle is located just distal and medial to the coronoid process and provides the attachment site for the anterior bundle of the MUCL [55].
• The LUCL complex originates at the geometric center of the radiocapitellar articulation, just distal to the lateral epicondyle [55].
• The LUCL origin center is 10.7 mm from the lateral epicondyle and its insertion is 3.3 mm from the apex of the supinator crest [53].
• Stability in full elbow extension is provided by the MCL, joint capsule, and ulnohumeral articulation [59, 60].

Biomechanics & Kinematics¶

• The normal elbow range of motion is 0° to 140° from extension to flexion [28].
• The normal elbow range of motion is 75° in pronation and 85° in supination [28].
• A functional arc of motion for the elbow is 100° for flexion and extension [28].
• A functional arc of motion for forearm rotation is 100° [28].
• The normal range of elbow flexion/extension is 0 to 150 degrees [59, 60].
• The normal forearm pronosupination is 80 to 85 degrees in each direction [59, 60].
• The functional range of motion for the elbow is 30 to 130 degrees flexion/extension and 50 degrees pronosupination [59, 60].
• The normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [59, 60].
• In full extension, 60% of axial load is transmitted through the radiocapitellar joint [59, 60].
• The ulnohumeral joint allows flexion and extension of the elbow [61].
• The radiocapitellar joint allows forearm rotation [61].
• Recent changes in device design and implantation methods are driven by biomechanical and clinical outcome-based research to better reproduce elbow kinematics [29].
• Shoulder abduction results in a varus moment at the elbow [69].
• The plane through the ridge of the greater sigmoid notch of a healthy proximal ulna could provide a more reliable anatomical landmark to estimate the position of the elbow flexion-extension axis compared to the posterior surface [104].
• The valgus angulation of available elbow implant designs is discordant with the mean native valgus angulation found in recent studies [95].
• The valgus laxity of current implants does not cover the variability in native valgus angulation observed in the studied population [95].

Pathophysiology & Disease Mechanisms¶

• Osteoarthritis of the elbow is characterized by osteophyte formation, capsular contracture, and loose bodies, often with relative preservation of the joint space [46].
• Periarticular hypertrophic osteophytes act as a mechanical block at the end ranges of flexion and extension in elbow osteoarthritis [46].
• Elbow osteoarthritis typically involves the radiocapitellar joint articular cartilage preferentially, with relative preservation of the ulnohumeral articular surfaces [46].
• Injury to primary and secondary stabilizers causes elbow instability [28].
• Cementing a nonanatomic hinge that may not rely on native elbow soft tissue support can result in a troubling biomechanical environment [74].
• Overstuffing the radial head prosthesis alters joint kinematics and may lead to pain and degenerative changes [92].
• The kinematics of the elbow deviate increasingly from those of the native joint with a 2 mm to 4 mm lengthening of the radius during radial head arthroplasty [56].
• Insertion of a correctly sized metallic radial head replacement recreates near-normal biomechanics of the forearm with no change in the loading characteristics of the interosseous membrane [77].
• From a biomechanical perspective, the enhancement of elbow stability with a monopolar radial head prosthesis is superior to that with a bipolar design [71].
• Radiocapitellar prosthetic arthroplasty largely preserves elbow kinematics and stability [50].

Classification¶

• The Mayo Classification is used to categorize periprosthetic fractures in total elbow arthroplasty [131].
• The Goldberg classification is used to assess radiographic loosening and component stability in total elbow arthroplasty [128].
• The American Rheumatoid Association classification is used to assess the functional severity of rheumatoid disease in patients undergoing ipsilateral shoulder and elbow arthroplasty [41].
• Radiographic arthritis severity is graded from grade 1 to grade 3 in the context of open débridement and débridement arthroplasty for elbow arthritis [20].
• Radiolucent lines in total elbow arthroplasty are classified into types I through IV based on progression and location [33].

Clinical Presentation¶

History and Symptoms¶

• Patients with primary osteoarthritis of the elbow typically present with loss of terminal extension and flexion [46].
• Patients with primary osteoarthritis of the elbow typically present with painful catching, clicking, or locking of the elbow [46].
• Pain in primary osteoarthritis of the elbow is typically noted at the end ranges of motion rather than through the midrange [46].
• Night pain is not typical for primary osteoarthritis of the elbow; if present, an inflammatory cause should be considered [46].
• The degree of disability caused by elbow osteoarthritis depends on the patient’s vocation and physical disability [46].
• A thorough history is invaluable for understanding the type of disease process and the degree that the condition affects the patient [123].
• Understanding whether a patient has pain throughout the arc of motion or only at terminal limits is of paramount importance in evaluation [123].
• Associated mechanical symptoms or instability must be evaluated during the history [123].
• Associated conditions such as cubital tunnel syndrome must be considered and evaluated to provide optimal management recommendations [123].
• The location, quality or type, context, duration, and severity of elbow pain are important for understanding pathology and focusing the physical examination [124].
• Prior treatments, including surgical interventions and injections, help in making the correct diagnosis [124].
• Determining the symptom trajectory (whether pain is getting better, worse, or remaining constant) is helpful when considering intervention [124].
• For elbow stiffness, the history should include the duration of the contracture, initial injury, previous surgical procedures, trials of splinting/therapy/injections, complications of surgery, and the patient’s work/life demands and goals [32].

Physical Examination¶

• The soft tissue surrounding the elbow should be examined for previous skin incisions, grafts, eschar, or infection [32].
• Active and passive flexion, extension, supination, and pronation should be evaluated using a goniometer for accurate measurement [32].
• The contralateral elbow should be examined for comparison during range of motion assessment [32].
• If the elbow has less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament is contracted and must be released to restore flexion [32].
• Mid-arc range of motion pain is more common with intrinsic disease and may not improve with contracture release alone [32].
• The ulnar nerve is of utmost importance in the physical examination due to its anatomic proximity to the elbow [32].
• Electromyography and nerve conduction velocity studies should be performed if there is any question about neurologic dysfunction [32].
• An assessment for ulnar nerve subluxation should be performed, as subluxation is a relative contraindication for arthroscopic procedures due to the risk of iatrogenic nerve injury [32].
• If a history of prior surgical procedures exists, verify if the ulnar nerve has been transposed [32].
• Inspection should check for prior surgical incisions and joint effusion at the lateral soft spot in patients with osteoarthritis [46].
• Forearm rotation is relatively preserved until later in the disease process of elbow osteoarthritis [46].
• Ulnar neuropathy is present in up to 50% of patients with elbow osteoarthritis [46].
• Loss of full extension is the first motion altered by most elbow pathology and the last to be regained [122].
• In a trauma situation, the likelihood of significant joint pathology in the face of normal elbow motion is so small as not to require radiographic analysis [122].
• Rupture of the triceps tendon or neurologic conditions should be suspected if there is loss of active extension [122].
• Loss of passive extension is a sensitive but nonspecific sign of an intra-articular process [122].
• The simple extension test has a sensitivity of 97% and a negative predictive value of 98% for elbow pathology [122].
• The specificity of the simple extension test is 69%, with a positive predictive value of 63% [122].
• The examiner should record both active and passive values for elbow motion [122].
• Any significant difference between active and passive ranges of motion suggests pain or motor dysfunction as the cause [122].
• In patients with flexion or extension contractures, the examiner should concentrate on solid or soft end points and pain or crepitus during the arc and at the end points [122].
• The upper extremity should be examined from the side with the hand in full supination to adequately assess for contracture [122].
• A careful assessment of any compromised motion at the shoulder or wrist should be made, as disability often arises from a combination of factors [122].
• Flexion contractures of less than 45° may have little practical significance, although patients may be concerned about the cosmetic appearance [122].
• To perform 90% of required daily activity, 50° of pronation and supination are required [122].
• Pronation is the most important function on the dominant side for eating and writing, and loss of pronation is compensated by shoulder abduction [122].
• Loss of supination on the nondominant side may significantly hinder personal hygiene needs, accepting objects, and opening door handles, and these tasks are poorly compensated by shoulder or wrist function [122].
• The radial head is driven into the capitellum with pronation by the screw-home mechanism [122].
• When combined with flexion or extension under a load (radiocapitellar load test), reproduction of radiocapitellar pain signals a problem with the joint [122].
• Crepitus can be noted during the radiocapitellar load test [122].
• Physical examination of the elbow should focus on functional anatomy, including inspection, palpation, range of motion, strength, stability, and special tests [124].
• Examination elements are dynamic, and adequate assessment often combines examination maneuvers to fully elucidate elbow pathology [124].
• A comprehensive physical examination aids in the diagnosis of specific pathologies related to functional anatomic elements including nerves, muscles and tendons, ligaments, articular elements, and bone [124].

Imaging¶

• Radiographs should always be obtained during the evaluation of elbow stiffness [32].
• AP, lateral, and oblique radiographs are standard for elbow stiffness evaluation [32].
• Serial radiography is used as follow-up when heterotopic ossification is present [32].
• Primary bony landmarks for radiographic evaluation include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [32].
• CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [32].
• Three-dimensional CT is used to check for heterotopic ossification [32].
• CT is not necessary when the stiffness is entirely soft-tissue related [32].
• If any joint incongruity or abnormal bony anatomy is present, CT is beneficial [32].
• MRI can be used to evaluate ligaments and tendons but is rarely indicated for elbow stiffness [32].
• Standard AP and lateral radiographs should be obtained for the evaluation of elbow osteoarthritis [46].
• Radiographs for elbow osteoarthritis typically show osteophyte formation at the coronoid process (anterior and medial), coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa [46].
• Joint spaces at the ulnohumeral joint are usually preserved in elbow osteoarthritis [46].
• Joint spaces at the radiocapitellar joint are mildly narrowed in elbow osteoarthritis [46].
• Loose bodies may be evident on radiographs, which typically underestimate the number present [46].
• CT may be useful for surgical planning of elbow osteoarthritis, allowing a detailed assessment of osteophytes and the presence of loose bodies [46].
• Plain radiographs should be obtained during the initial workup to evaluate the articular surface and bony anatomy [123].
• CT scans with 3D reconstructions may be useful for evaluating the extent and location of disease and for surgical planning [123].
• MRI may be useful to evaluate the status of the soft tissues, including the medial and lateral collateral ligamentous complexes [123].
• Electromyography and nerve conduction studies may be useful to evaluate the degree of nerve compression and contribution to elbow pain and/or dysfunction [123].

Investigations¶

Physical Examination and History¶

• The physical examination of the elbow is directed by the history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect [28].
• An assessment for ulnar nerve subluxation should be performed, as subluxation is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [32].
• Function of the upper extremity, including the shoulder, wrist, and hand, should be assessed during the physical examination [32].

Imaging¶

• Plain radiographs remain the hallmark and the best screening test for elbow evaluation [28].
• AP, lateral, and oblique radiographs are standard for elbow evaluation [32].
• CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes or loose bodies [32].
• CT is beneficial if any joint incongruity or abnormal bony anatomy is present [32].
• MRI can be used to evaluate ligaments and tendons, but it is rarely indicated for elbow stiffness [32].
• MRI is the imaging modality best suited for evaluating soft-tissue structures in the elbow, including ligaments, tendons, cartilage, and nerves [65].
• Conventional MRI sequences should be obtained in all three planes using T1-weighted and fluid-sensitive sequences [65].
• Magnetic resonance arthrography is particularly beneficial in the evaluation of osteochondral lesions, loose bodies, and ulnar collateral ligament injury in a throwing athlete [65].
• Coronal MRI studies should be obtained along a line connecting the medial and lateral epicondyles [65].
• Sagittal MRI studies should be perpendicular to the coronal studies [65].
• MRI units with a 3-Tesla magnetic field strength can generate high signal-to-noise ratios and are more able to show normal anatomy than a 1.5-Tesla unit [65].
• 3-Tesla imaging can show mild signal alterations of tendons, ligaments, and nerves of the elbow that may not be symptomatic [65].
• Ultrasonographic soft-tissue evaluation in the elbow is most useful in evaluating the distal biceps and the common flexor and extensor tendons [65].
• Ultrasonography allows dynamic imaging, which may be useful in evaluating for ulnar nerve subluxation or a snapping triceps [65].
• CT can be helpful in identifying mineralized intra-articular loose bodies or delineating the anatomy of a complex intra-articular fracture [65].
• The primary bony landmarks for radiographic evaluation include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [32].

Preoperative Planning and Surveillance¶

• The radial head arthroplasty diameter can be predicted preoperatively in two-thirds of cases from a simple measurement of the humeral condyle diameter with an appropriate lateral view of a simple radiograph [137].
• Continued radiological surveillance is warranted for humeral lucency in linked total elbow replacements [9].
• Surveillance efficacy is higher in primary linked total elbow arthroplasty than primary shoulder arthroplasty [11].
• Poor ulnar cementation may predict radiological loosening and eventual need for revision, but this loosening does not correlate with the patient's clinical outcomes [147].
• The overall interobserver reliability of radiographic assessment following press-fit bipolar radial head arthroplasty was poor among experienced elbow surgeons [150].
• Heterotopic ossification after total elbow arthroplasty is seen more commonly than previously reported [141].

Treatment¶

Indications and Patient Selection¶

• The primary indications for total elbow arthroplasty are pain and/or instability [44].
• Deformity and dysfunction without pain are not indications for surgery [44].
• An unreconstructible distal humeral fracture in an elderly patient is an increasingly common indication for total elbow arthroplasty [44].
• Rheumatoid arthritis with radiographic evidence of joint destruction too far advanced to benefit from radial head excision and synovectomy is generally considered an indication for total elbow arthroplasty [44].
• The emergence of immunomodulating disease-remitting agents for rheumatoid arthritis has largely been responsible for a decrease in the number of total elbow arthroplasties performed for this indication [44].
• Elderly patients with end-stage posttraumatic sequelae are acceptable candidates for total elbow replacement [44].
• Bony or fibrous ankylosis with the elbow in a poorly functioning position is an indication for elbow arthroplasty [44].
• In patients with rheumatoid arthritis, arthroplasty should be considered only after medical treatment has failed and the disease has advanced to show bony changes beyond the stage at which synovectomy would be beneficial [44].
• Patients with rheumatoid arthritis who have limitation of motion, ankylosis, instability, or incapacitating pain generally do better after implant arthroplasty than do patients with posttraumatic arthritis [44].
• A history of previous elbow sepsis is an absolute contraindication to prosthetic elbow implant arthroplasty according to Ewald [44].
• Infection, excessive use of the elbow, ankylosis of the ipsilateral shoulder, and the presence of neurotrophic joints are considered contraindications by Coonrad and Morrey [44].
• Extensive bone loss on either side of the joint and poorly functioning flexor and extensor mechanisms are contraindications according to Kudo et al. [44].
• Higher demand, male gender, trauma-related indications, and young age have consistently been linked to poorer outcomes and higher risk of revision following total elbow arthroplasty [43].
• Obese patients being considered for elbow replacement surgery should be counseled accordingly [42].
• The range of indications for total elbow arthroplasty is broadening, with use for acute trauma and osteoarthritis becoming increasingly more common [15].
• Total elbow arthroplasty is a surgical option for end-stage elbow arthritis with indications expanding from rheumatoid arthritis to osteoarthritis, post-traumatic arthritis, and acute fractures [37].
• Treatment of elbow arthritis must be individualized based on etiology, severity, patient age, and functional demands [13].
• Nonsurgical management may provide relief in early stages of elbow arthritis [13].
• Surgical options for elbow arthritis range from arthroscopic debridement for pain at motion extremes to total elbow arthroplasty for pain throughout the arc of motion [13].
• Functional improvement is possible by means of total elbow replacement when proper indications are satisfied, including patient understanding of risks and ability to comply with postoperative rehabilitation [22].
• Elbow hemiarthroplasty is an option for young or active patients with end-stage elbow arthritis or unreconstructable distal humerus fractures in whom alternative procedures have failed or there are few other options for treatment [45].
• Total elbow arthroplasty performed acutely for distal humerus fractures results in satisfactory outcomes and should be a consideration for patients at high risk of failing open reduction internal fixation or nonsurgical management [47].
• Salvage of supracondylar non-union by means of a total elbow arthroplasty is a technically demanding procedure that should be done only when other therapeutic options are unsatisfactory [87].
• A pedicled vascularized bone graft represents an alternative to the use of hemi or total elbow replacement in younger patients who have undergone multiple prior surgeries for intra-articular distal humerus recalcitrant nonunion [54].

Implant Design and Biomechanics¶

• Recent changes in device design and implantation methods are driven by biomechanical and clinical outcome-based research to better reproduce elbow kinematics, resulting in more durable and long-lasting joint replacement procedures [29].
• Initial fixed-hinge designs were plagued with failure because the hinges were fully constrained, allowing less than 1 degree of varus-valgus laxity, and transferred profound forces through the bone-implant interface [43].
• Unlinked implants rely on intact capsuloligamentous restraints for stability and function and promise to dissipate forces through the ligaments and capsule to shield the cement-bone interface [43].
• Unconstrained implants are less forgiving when placed in malalignment or with poor soft tissue stability and have a higher risk of instability compared with constrained options [43].
• The semiconstrained total elbow arthroplasty was developed in the 1970s to provide inherent stability and the reproducibility of a hinged prosthesis with a "sloppy hinge" to help shield the bone-implant interface and lower aseptic loosening [43].
• The loose coupling of the humeral and ulnar components in semiconstrained implants allows 7 degrees of varus-valgus and 7 degrees of axial rotation, enabling forces to be dissipated through the capsule and ligaments without allowing instability [43].
• Clinical success and technical simplicity have led to the popularity of semiconstrained implant designs [43].
• Convertible models allow simpler conversion from unconstrained to semiconstrained implants [43].
• A 2005 systematic review showed 78% good-excellent results for total elbow arthroplasty, which were more common for semiconstrained implants (82%) versus unlinked (78%) versus fixed hinge (73%) [43].
• A 2011 systematic review suggested an overall 24.3% complication rate, which was slightly lower for linked (25.9%) versus unlinked (27.2%) prostheses [43].
• Linked implants did not have higher clinical loosening (5.2%) compared with unlinked implants (5.2%) in a 2011 systematic review [43].
• Clinical instability was lower in linked implants (1.4%) versus unlinked implants (4.9%) in a 2011 systematic review [43].
• A recent review showed decreased aseptic loosening of linked compared with unlinked prostheses (p < 0.005) [43].
• Revision rates were lower for linked implants (13.8%) versus unlinked implants (16.3%; p = 0.015) in a recent review [43].
• Selection of the type of prosthetic implant depends to a great extent on the state of the capsuloligamentous structures around the elbow and the integrity of the musculature and the amount of bone remaining at the elbow joint [44].
• Generally, the more bone remaining and the more stable the joint, the more suitable the joint is for replacement with a resurfacing or unconstrained prosthetic implant [44].
• More constrained prosthetic designs should be selected for patients with injury to the stabilizing ligaments and capsule of the joint, atrophic musculature, and loss of considerable bone stock [44].
• Linking the Latitude total elbow prosthesis results in increased valgus stability [106].
• The Latitude prosthesis provides patients with favorable clinical outcomes with improvements in their range-of-motion and a complication rate comparable to other elbow arthroplasty implants [36].
• With careful patient selection, convertible total elbow arthroplasty provides patients with good to excellent outcomes and substantial improvements in the range of movements [17].
• In most cases, elbow function was maintained in the long-term without loosening of the implant in Kudo type-5 total elbow arthroplasty for patients with rheumatoid arthritis [3].
• Total elbow arthroplasty for fracture in elderly patients provides pain relief, functional range of motion, and good patient-reported outcome scores [130].
• Patients with elbow arthroplasty had moderate pain, but limited grip strength and range of motion, 1 year to 5 years after surgery [135].

Surgical Approaches¶

• The review discusses various approaches to total elbow arthroplasty and their reported outcomes to assist surgeons in making an informed choice [6].
• Management of the triceps is guided by the underlying pathology, implant type, and surgeon preference [127].
• The main types of approach used in total elbow arthroplasty are triceps-splitting, -reflecting, and -sparing [127].
• Triceps-splitting approaches involve either longitudinal division of the triceps in continuity with the forearm fascia over the dorsal ulna or splitting of the proximal triceps muscle belly with a V-shaped turndown of the triceps tendon and leaving intact its insertion on the olecranon [127].
• The latter triceps-splitting approach allows for lengthening of the extensor mechanism in cases of extension contracture [127].
• The triceps-reflecting (Bryan-Morrey) approach has traditionally been used for elbow replacement [127].
• In the triceps-reflecting approach, the triceps is reflected from medial to lateral in continuity with the anconeus muscle [127].
• At the conclusion of the triceps-reflecting surgery, the triceps is reattached to the ulna through cruciate tunnels using nonabsorbable suture passed through the triceps tendon [127].
• An additional horizontal tunnel in the triceps-reflecting approach allows passage of suture to cinch the triceps securely to the olecranon to prevent synovial fluid extravasation behind the repair [127].
• Due to increased awareness of triceps insufficiency as a complication of a triceps-reflecting approach, many surgeons have sought to maintain the integrity of the triceps intraoperatively [127].
• A triceps-sparing approach has been advocated for total elbow arthroplasty to manage acute fracture of the distal humerus [127].
• Removal of the distal fracture fragments in a triceps-sparing approach helps to maintain the triceps and achieve adequate exposure for component implantation [127].
• A triceps-sparing approach can also be used for total elbow arthroplasty when the distal humerus remains intact, although it is more difficult to gain the necessary exposure for component insertion [127].
• The Van Gorder approach is the largest study evaluated for the surgical approach to the elbow for primary total elbow arthroplasty with an average follow-up of 32 months [68].
• The STOMP (Selective Triceps-On Medial Paraolecranon) approach is a safe approach for elbow arthroplasty surgery that does not detach the triceps and offers improved exposure and safety compared to other triceps-on techniques [72].
• The medial single-window approach to the elbow ensures sufficient visualization for total elbow arthroplasty while minimizing postoperative complications and allowing early safe mobilization [73].
• The "global" approach allows circumferential exposure of the elbow, reaching the collateral ligaments, coronoid process, and anterior joint capsule [31].
• In the global approach, if the medial aspect of the elbow is to be exposed, the cubital tunnel is opened, the ulnar nerve is isolated and transposed anteriorly, and it is protected throughout the procedure with a Penrose drain [31].
• The posterolateral component of the global approach develops the Kocher interval between the anconeus and extensor carpi ulnaris muscle to expose the elbow capsule and lateral epicondyle [31].
• To expose the olecranon fossa and posterior aspect of the distal humerus in the global approach, the anconeus and triceps are reflected medially [31].
• To expose the radial head in the global approach, the common extensor origin is elevated anteriorly from the underlying capsule, lateral ulnar collateral ligament, and lateral epicondyle [31].
• An arthrotomy is made along the anterior border of the lateral ulnar collateral ligament and carried distally, dividing the annular ligament in the global approach [31].
• If additional exposure of the radial head is needed in the global approach, a chevron osteotomy of the lateral epicondyle is performed [31].
• If additional exposure of the radial head, neck, and proximal shaft is needed in the global approach, the forearm is pronated to translate the posterior interosseous nerve anteriorly and the annular ligament is divided 5 mm from the edge of the lesser sigmoid notch [31].
• The posteromedial component of the global approach involves releasing the flexor carpi ulnaris and flexor digitorum profundus muscles subperiosteally from their ulnar origins to extend the approach medially [31].
• Retraction anteriorly in the posteromedial component of the global approach exposes the coronoid process, the anterior bundle of the medial ligament complex, and anterior joint capsule [31].
• The selected approach for elbow hemiarthroplasty should allow sufficient access for articular fragment resection, condyle/collateral ligament repair and humeral instrumentation, as well as sufficient exposure of the radial head and ulna to allow accurate sizing of the articular components [111].
• A commonly described approach for elbow hemiarthroplasty is via an olecranon osteotomy, which affords good visualization of the distal humeral articular surface but requires fixation with further hardware [111].
• Of 39 reported cases of olecranon osteotomy for elbow hemiarthroplasty, 13 patients (33%) required further surgery for problems related to the olecranon osteotomy [111].
• Violating the olecranon with an osteotomy may exacerbate ulna wear concerns after elbow hemiarthroplasty [111].
• If there is instability on trialling the elbow hemiarthroplasty, conversion to total elbow arthroplasty may be compromised by an olecranon osteotomy [111].
• The most commonly described approach in the literature for elbow hemiarthroplasty has been the triceps split by Adolfsson’s group in Scandinavia [111].
• Twenty-two reported cases used a 'triceps on' approach for elbow hemiarthroplasty [111].
• The 'triceps on' approach for elbow hemiarthroplasty facilitates early-unrestricted range of motion and negates the issues of subcutaneous hardware and triceps failure [111].
• As part of the surgical approach for elbow hemiarthroplasty, the ulnar nerve is identified, mobilized and protected but is not routinely transposed unless it lies in a specific position [111].
• The extended deltopectoral approach is used for revision total elbow arthroplasty requiring humeral allograft-prosthetic composites in patients with severely compromised proximal humerus bone stock [115].
• In the extended deltopectoral approach, the patient is placed supine with the torso angled approximately 60° cephalad in the 'high beach chair' or 'barber chair' position [115].
• No tourniquet is used in the extended deltopectoral approach given the proximal extent of the planned dissection [115].
• The incision for the extended deltopectoral approach is marked from just lateral to the coracoid process proximally to mid-anterior proximal forearm distally [115].
• The distal dissection in the extended deltopectoral approach is carried across and past the elbow flexion crease to facilitate component uncoupling and recoupling [115].
• The proximal dissection in the extended deltopectoral approach is carried down to the humerus via the deltopectoral interval [115].
• Distally, the radial nerve is found between the brachialis and the brachioradialis in the extended deltopectoral approach, and a vessel loop is placed around it [115].
• The radial nerve is mobilized and the brachialis is split in order to expose the humeral shaft in the extended deltopectoral approach [115].
• The dissection is carried distally to the coupling mechanism of the total elbow arthroplasty in the extended deltopectoral approach [115].
• A whole humerus allograft is prepared and cemented with the humeral component of the total elbow arthroplasty on the back table in the extended deltopectoral approach [115].
• The allograft-prosthetic composite is placed into the wound and the total elbow arthroplasty components are aligned in the extended deltopectoral approach [115].
• Traction is applied to the arm, and the length and rotation are assessed in the extended deltopectoral approach [115].
• The allograft-prosthetic composite is marked for the site of the osteotomy and then cut in the extended deltopectoral approach [115].
• The allograft-prosthetic composite is secured to the remaining native proximal humerus with interfragmentary screws and a long proximal humerus plate in the extended deltopectoral approach [115].
• For revision total elbow arthroplasty using intramedullary strut allograft, the original midline incision made for the primary arthroplasty is used [126].
• A triceps sparing approach is preferred for both primary and revision elbow arthroplasty to allow for early active range of motion postoperatively [126].
• It is of critical importance to carefully identify and protect the ulnar nerve before mobilizing the triceps in revision total elbow arthroplasty [126].
• A Penrose drain is loosely secured around the ulnar nerve once it is identified to make it easily identified and manipulated throughout the duration of the procedure [1

Complications¶

General Complication Rates and Outcomes¶

• The overall significant complication rate for modern total elbow arthroplasty is 24.3% ± 5.8% [148].
• An overall complication rate in total elbow arthroplasty of up to 43% has been reported, including an 18% revision rate and 15% “permanent” complications [40].
• A recent meta-analysis reported a 13.5% revision rate for total elbow arthroplasty, with aseptic loosening, infection, and periprosthetic fracture as the most common indications for reoperation [40].
• Complications occurred in 21% of patients undergoing total elbow arthroplasty and lead to a decrease in satisfaction and Oxford Elbow Score after 3 years, despite no significant differences at 1-year or 5-year follow-up [149].
• Survival rates for the Latitude primary total elbow arthroplasty remain low and complication rates remain high yet are comparable to those of other elbow arthroplasties [25].
• Secondary total elbow arthroplasty after failed internal fixation has shown good functional results and a complication rate comparable to that of index total elbow arthroplasty in the treatment of articular fractures of the distal humerus in the elderly [138].
• Primary arthroplasty as treatment of distal humeral fractures produces reliable results with regards to revisions and other adverse events [146].
• The complication rates quoted for elbow arthroplasty in the rheumatoid vary considerably, with rates reported from 14% to 80% and a median of 33% [63].
• A recent large series in the German literature of over 170 cases of primarily linked but also unlinked implants performed between 1987 and 2005 recorded a complication rate of 34.4% [63].
• The Kudo elbow prosthesis complication rate of 24% is slightly lower than the average reported for rheumatoid elbow arthroplasty [63].
• In a five-year experience at the Mayo Clinic from 1973 through 1977, there were forty-four complications (55 per cent) after eighty total elbow arthroplasty procedures [119].
• Most of the complications in the early Mayo Clinic series occurred during the early years of the study [119].

Infection¶

• Total elbow arthroplasty carries a higher risk of infection when compared to other major joint replacements [19].
• Infection is a dreaded complication of total elbow arthroplasty, with a reported incidence of 0% to 11.5% and an average of 5% to 6% [40].
• Persistent wound drainage is highly indicative of deep infection and predicts the likelihood of subsequent component resection [40].
• Two-stage revision is generally recommended for infection after total elbow arthroplasty, with reports indicating an acceptable level of eradication [40].
• Well-fixed components may be retained at the time of initial debridement and placement of local antibiotics for infected total elbow arthroplasty [40].
• After completion of a course of intravenous antibiotics, a repeat debridement with re-articulation of the components can be successful for infected total elbow arthroplasty [40].
• Periprosthetic joint infection after total elbow arthroplasty is relatively common and difficult to eradicate, with prevention being key [152].
• The reduction in periprosthetic joint infection seen in a cohort using intravenous vancomycin has changed the practice of the authors, who now routinely administer vancomycin powder for total elbow arthroplasty [153].
• Surgical helmet systems do not reduce the incidence of periprosthetic joint infections in elbow arthroplasty based on results from the New Zealand National Joint Registry, 2000-2023 [156].
• Patients with rheumatoid arthritis have higher infection rates than those with posttraumatic sequelae [40].
• In a two-stage reimplantation study, two-stage reimplantation may lead to the eradication of infection in approximately 70% of the elbows [120].
• Persistent reinfection rates after total elbow arthroplasty have been reported previously in the literature, ranging between 20% and 28% [120].
• Even for elbows with surviving implants after two-stage reimplantation, good or excellent results according to the Mayo Elbow Performance Score are obtained in only 60% of the elbows [120].
• The non-infection related adverse event rate for one-stage revision of infected elbow prostheses was 16.7% (95% CI: 3.0–56.4) [117].
• The non-infection related adverse event rate for two-stage revision of infected elbow prostheses ranged from 11.8% (95% CI: 4.7–26.6) to 20.0% (95% CI: 3.6–62.4) over a weighted mean followup period of 3.7 years [117].
• None of the six studies reporting on mortality outcomes for one- or two-stage surgical revision of infected elbow prostheses reported any mortality event associated with the revision strategy [117].

Wound and Soft Tissue Complications¶

• The overall incidence of soft tissue wound complication after total elbow arthroplasty was 5.5% in a study of 97 patients [34].
• 81% of patients in a study of early postoperative wound complications had a history of elbow surgery in the affected limb for various types of fracture fixation, failed arthroplasty, open or arthroscopic synovectomies, and bone graft procedures [34].
• Wound problems occur in 14% of total elbow arthroplasty cases on average [40].
• Superficial wound infections were reported in three out of 391 radial head arthroplasty cases (0.77%) and resolved completely with oral antibiotics [108].
• Deep postoperative infection was reported in one case of EVOLVE radial head prosthesis, which was removed as a result of an associated elbow contracture [108].

Neurological Complications¶

• Nerve paresthesias occur in 11% of total elbow arthroplasty cases on average [40].
• Nerve entrapment occurs in 3% of total elbow arthroplasty cases on average and usually requires surgery [40].
• A 3% incidence of significant ulnar nerve complications after total elbow arthroplasty compares favorably with systematic reviews [48].
• Transient neuropathy of ulnar nerve and posterior interosseous nerve were the most commonly reported neurological complications in radial head arthroplasty, occurring in seven out of 391 cases (4.73%) [108].
• In the majority of radial head arthroplasty cases with transient neuropathy, the symptoms resolved spontaneously with no residual disability [108].
• Only two reported cases of radial head arthroplasty required transposition of the ulnar nerve [108].
• Radial nerve palsy is an uncommon complication after humeral revision in total elbow arthroplasty, occurring in 7 of 258 cases (2.7%) [84].
• Only 3 of 7 patients (43%) with radial nerve palsy after humeral revision in total elbow arthroplasty regained function [84].
• There was no recovery in 4 out of the 5 patients in whom power instruments or ultrasound was used for cement removal during humeral revision [84].
• Two of three patients who underwent exposure of the radial nerve had return of function at most recent follow-up after humeral revision [84].
• Formal exposure and protection of the radial nerve are predictive of recovery from radial nerve palsy after humeral revision in total elbow arthroplasty [84].

Mechanical and Structural Complications¶

• Triceps problems occur in 4% of total elbow arthroplasty cases on average and usually require surgery [40].
• Ankylosis occurs in 4% of total elbow arthroplasty cases on average and usually requires surgery [40].
• Loosening of semiconstrained prostheses occurs in 5% of total elbow arthroplasty cases on average and usually requires revision [40].
• Instability of unconstrained prostheses occurs in 9% of total elbow arthroplasty cases on average and usually requires revision [40].
• Infection occurs in 7% of total elbow arthroplasty cases on average and usually requires revision [40].
• Fracture and loosening occurs in 5% of total elbow arthroplasty cases on average and usually requires revision [40].
• Fracture of the humerus occurs in 5% of total elbow arthroplasty cases on average and rarely requires surgery [40].
• Fracture of the ulna occurs in 5% of total elbow arthroplasty cases on average and rarely requires surgery [40].
• Instability in the form of dislocation or subluxation is the most common complication requiring revision of unconstrained prostheses and has been reported to occur in between 9% and 10% of total elbow arthroplasties [40].
• True dislocation occurs in fewer than 5% of unlinked implants and is dependent on surgical technique [40].
• Appropriate tensioning of the medial and lateral ligament complexes and preservation of the anterior capsule and triceps can help avoid dislocation in total elbow arthroplasty [40].
• A principal complication of unconstrained total elbow arthroplasty has been loosening, usually of the humeral component [40].
• For semiconstrained prostheses, loosening of the humeral component, previously the most common cause for revision, has been reduced with improvements in prosthesis design, changes in operative technique, and better understanding of the anatomy and function of the elbow [40].
• Use of a shorter (4 inch) stem in semiconstrained total elbow arthroplasty resulted in earlier time to revision than longer (6 inch) stems [40].
• Humeral stem loosening remained uncommon at a rate of approximately 2% at an average of 7 years of follow-up [40].
• Ulnar component loosening and osteolysis increased with the addition of a polymethylmethacrylate precoat in the 1990s but has decreased since the surface finish was changed to a plasma spray preparation [40].
• Wear of the polyethylene bearing surface has been reported after total elbow arthroplasty but accounts for a minority of revision procedures [40].
• Factors associated with the development of bushing wear in total elbow arthroplasty include younger patient age, male sex, posttraumatic arthritis, preoperative elbow deformity, supracondylar nonunion, and high activity levels [40].
• Implant malalignment has been implicated in a biomechanical model for polyethylene bearing surface wear in total elbow arthroplasty [40].
• Biomechanical testing of vitamin E-infused polyethylene indicates it is a promising alternative to reduce bearing surface wear, but it is not yet supported by clinical data [40].
• Osteolytic reaction similar to that seen in total hip and knee replacements has been found in total elbow replacement [40].
• In a retrieval study of 16 elbows, multiple modes of wear were observed, including asymmetric thinning of the humeral and ulnar bearing surfaces and metal-on-metal debris [40].
• Polyethylene particles, cement, and metal debris were all found at the time of total elbow revision in another study [40].
• Osteolysis in total elbow arthroplasty is a multifactorial process [40].
• The high rate of component loosening in total elbow arthroplasty after failed internal fixation may be related to the increased pathology and technical difficulty of elbow joint arthroplasty in the setting of prior failed internal fixation [142].
• We found acceptable implant survival rates after 5 and 10 years, with a higher revision rate for the unlinked design and primary TEA due to fracture sequelae [151].
• The ulnar component remains the problematical part of the Kudo prosthesis being more commonly affected by aseptic loosening and malalignment (tilting) [63].

Radial Head Arthroplasty Complications¶

• One or more complications were observed in 38 elbows (30.9%) in a study of radial head arthroplasty without cement for unreconstructible radial head fractures [35].
• The most common complications in radial head arthroplasty without cement were painful implant loosening (14 [29.2% of 48 complications]) and subluxation/dislocation of the prosthesis (9 [18.8%]) [35].
• Twenty-eight elbows (22.8%) underwent revision surgery with ≥1 procedures performed in a study of radial head arthroplasty without cement [35].
• The most common revision procedure for radial head arthroplasty without cement was implant removal (15 [38.5% of 39 revisions]), followed by arthrolysis (12 [30.8%]) [35].
• The median time to revision for radial head arthroplasty without cement was 1.1 years (IQR, 0.3 to 3.8 years) [35].
• Most revision surgeries (17 [60.7%]) for radial head arthroplasty without cement occurred within the first 2 years after surgery [35].
• Another 11 elbows (39.3%) went on to revision surgery after 2 years in a study of radial head arthroplasty without cement [35].
• Implant removal was required in 11 out of 391 radial head implants (3.06%) [108].
• Eight out of 391 radial head implants required revision surgeries (2.22%) [108].
• Loss of flexion after radial head replacement is a reported complication [12].

Surveillance and Monitoring¶

• Surveillance efficacy is higher in primary linked total elbow arthroplasty than primary shoulder arthroplasty, supporting appropriate resource allocation for elbow arthroplasty surveillance [11].
• Postoperative plain radiographs of 49 patients with Coonrad-Morrey total elbow arthroplasty showed no evidence of radiolucency in 21 elbows (43%) [33].
• Progressive humeral radiolucent lines were revealed in seven elbows (14%) in a study of Coonrad-Morrey total elbow arthroplasty in young patients [33].
• Ulnar radiolucent lines were also revealed in three elbows (6%) in a study of Coonrad-Morrey total elbow arthroplasty in young patients [33].
• Low-grade humeral radiolucency was detected in 15 elbows (31%) in a study of Coonrad-Morrey total elbow arthroplasty in young patients [33].
• Nonprogressive ulnar radiolucent lines were detected in six elbows (12%) in a study of Coonrad-Morrey total elbow arthroplasty in young patients [33].

Mortality and Systemic Complications¶

• Perioperative mortality has been reported to be 0.6% and is most commonly caused by cardiac complications [40].
• There is a lack of good quality evidence regarding the risks and benefits of venous thromboembolism prophylaxis in upper limb major joint replacement surgery [129].

Prevention and Technique¶

• A number of measures have been recommended to minimize the occurrence of other complications of elbow implant arthroplasty, especially infection and problems with the triceps, ulnar nerve, and wound healing [40].
• Recommended measures to minimize complications include the use of a straight incision medial to the olecranon tip [40].
• Recommended measures to minimize complications include detachment of the triceps in continuity from the olecranon without division of the tendon or the use of a triceps-on approach [40].
• Recommended measures to minimize complications include anterior transposition of the ulnar nerve [40].
• Recommended measures to minimize complications include drainage of the wound with at least one suction drain [40].
• Recommended measures to minimize complications include initial splinting of the elbow in full extension [40].
• Bone quality and loss are critical factors in determining revision strategy for failed total elbow arthroplasty [21].

Recovery¶

• Postoperative rehabilitation for primary total elbow arthroplasty involves immobilization in a bulky dressing and splint for 5 days [14].
• Active and passive range of motion is initiated if the wound is sealed at 5 days postoperatively [14].
• An extension splint is used at night as needed to maintain full elbow extension [14].
• Activities of daily living are encouraged during the recovery period [14].
• Extension against resistance is prohibited for 6 weeks after surgery if the triceps was detached for exposure [14].
• Patients are given a lifting restriction of 5 lbs [14].
• Clinical and radiographic evaluations occur at postoperative intervals of 3 months, 6 months, 1 year, and then annually thereafter up to 5 years [14].
• The modified posterior approach enables early mobilization after total elbow arthroplasty [109].
• Ninety-four percent of patients engaged in moderate-demand activities after total elbow arthroplasty [91].
• Forty percent of patients engaged in high-demand activities after total elbow arthroplasty [91].
• Functional improvement is possible by means of total elbow replacement when the patient understands risks and is able to comply with postoperative rehabilitation [22].

Key Evidence¶

• [L5] Continued advances in exposure, implant design, and complication management are key to making elbow arthroplasty as reliable and lasting as hip or knee arthroplasty. [1] (10.1177/1758573216677200)
• [L5] The continued success of total elbow arthroplasty will depend on advances in surgical planning, technique, implant design, and materials. [2] (10.5435/jaaos-d-25-00473)
• [L3] In most cases, elbow function was maintained in the long-term without loosening of the implant. [3] (10.1302/0301-620x.99b6.bjj-2016-1033.r2)
• [L3] Patients undergoing elective total elbow arthroplasty have slightly higher complication rates than those undergoing shoulder, hip, or knee arthroplasty. [4] (10.1016/j.jhsa.2016.07.007)
• [L4] The review discusses various approaches to total elbow arthroplasty and their reported outcomes to assist surgeons in making an informed choice. [6] (10.1177/1758573216682479)
• [L4] The complication and revision rates are comparable to other indications for elbow replacement surgery. [7] (10.1177/17585732211014832)
• [L3] The Discovery elbow replacement demonstrates early clinical results similar to other semi-constrained total elbow replacements, with continued radiological surveillance warranted for humeral lucency. [9] (10.1302/0301-620x.96b10.33815)
• [L4] Surveillance efficacy is higher in primary linked total elbow arthroplasty than primary shoulder arthroplasty, supporting appropriate resource allocation for elbow arthroplasty surveillance. [11] (10.1177/17585732241301356)
• [L5] Treatment of elbow arthritis must be individualized based on etiology, severity, patient age, and functional demands; nonsurgical management may provide relief in early stages, while surgical options range from arthroscopic debridement for pain at motion extremes to total elbow arthroplasty for pain throughout the arc of motion. [13] (10.1016/j.jhsa.2012.12.037)
• [L4] [14] (10.1016/j.jse.2013.12.033)
• [L2] The range of indications for total elbow arthroplasty is broadening; total elbow arthroplasty for acute trauma and osteoarthritis is becoming increasingly more common. [15] (10.1302/2058-5241.5.190036)
• [L4] It is a satisfactory alternative to total elbow arthroplasty with lower rates of complications and does not require activities to be restricted to the same extent. [16] (10.1302/0301-620x.100b3.bjj-2017-0865.r1)
• [L4] With careful patient selection, convertible total elbow arthroplasty provides patients with good to excellent outcomes and substantial improvements in the range of movements. [17] (10.1177/1758573221991511)
• [L4] Total elbow arthroplasty carries a higher risk of infection when compared to other major joint replacements. [19] (10.1177/1758573218789341)
• [L4] [20] (10.1016/j.jse.2022.01.138)
• [L5] The article provides a comprehensive review of current strategies to improve diagnosis of failed total elbow arthroplasty and management of bone loss, noting that bone quality and loss are critical factors in determining revision strategy. [21] (10.1016/j.xrrt.2023.02.010)
• [L4] Functional improvement is possible by means of total elbow replacement when proper indications are satisfied, including patient understanding of risks and ability to comply with postoperative rehabilitation. [22] (10.2106/00004623-198971040-00006)
• [L4] Survival rates nonetheless remain low and complication rates remain high yet are comparable to those of other elbow arthroplasties. [25] (10.1016/j.jse.2021.08.028)
• [L5] Recent changes in device design and implantation methods are driven by biomechanical and clinical outcome-based research to better reproduce elbow kinematics, resulting in more durable and long-lasting joint replacement procedures. [29] (10.1302/2058-5241.2.160064)
• [L4] [33] (10.1016/j.jse.2022.03.021)
• [L4] [34] (10.1016/j.jse.2011.03.005)
• [L4] [35] (10.2106/jbjs.20.01231)
• [L4] The Latitude prosthesis provides patients with favorable clinical outcomes with improvements in their range-of-motion and a complication rate comparable to other elbow arthroplasty implants. [36] (10.1177/1758573218768510)
• [L4] Total elbow arthroplasty is a surgical option for end-stage elbow arthritis with indications expanding from rheumatoid arthritis to osteoarthritis, post-traumatic arthritis, and acute fractures. [37] (10.1016/j.jhsa.2018.11.005)
• [L4] [41] (10.2106/00004623-198870010-00031)
• [L3] Obese patients being considered for elbow replacement surgery should be counseled accordingly. [42] (10.2106/jbjs.m.00364)
• [L4] Elbow HA is an option for young or active patients with end stage elbow arthritis or unreconstructable distal humerus fractures in whom alternative procedures have failed or there are few other options for treatment. [45] (10.1016/j.jse.2015.11.048)
• [L3] The study suggests that total elbow arthroplasty performed acutely results in satisfactory outcomes and should be a consideration for patients at high risk of failing ORIF or nonsurgical management. [47] (10.1016/j.jhsg.2023.05.006)
• [L4] A 3% incidence of significant ulnar nerve complications after total elbow arthroplasty compares favorably with systematic reviews. [48] (10.1016/j.jhsa.2015.06.107)
• [L4] The procedure largely preserves elbow kinematics and stability. [50] (10.1016/j.jse.2014.01.042)
• [L4] This approach represents an alternative to the use of hemi or total elbow replacement in younger patients who have undergone multiple prior surgeries. [54] (10.1016/j.jseint.2024.06.002)
• [L5] The kinematics of the elbow deviated increasingly from those of the native joint with a 2 mm to a 4 mm lengthening of the radius. [56] (10.1302/0301-620x.106b10.bjj-2024-0405.r1)
• [L3] [63] (10.1111/j.1758-5740.2009.00011.x)
• [L4] This is the largest study evaluating the Van Gorder surgical approach to the elbow for primary TEA with an average follow-up of 32 months. [68] (10.1016/j.jse.2021.09.005)
• [L5] Shoulder abduction results in a varus moment at the elbow. [69] (10.1016/j.jhsa.2018.04.022)
• [L5] From a biomechanical perspective, the enhancement of elbow stability with a monopolar radial head prosthesis is superior to that with a bipolar design. [71] (10.1016/j.jse.2010.10.033)
• [L4] The STOMP approach is a safe approach for elbow arthroplasty surgery that does not detach the triceps and offers improved exposure and safety compared to other triceps-on techniques. [72] (10.1016/j.jseint.2024.12.003)
• [L4] This approach ensures sufficient visualization for total elbow arthroplasty while minimizing postoperative complications and allowing early safe mobilization. [73] (10.1016/j.xrrt.2025.08.016)
• [L5] Cementing a nonanatomic hinge that may not rely on the native elbow soft tissue support can result in a troubling biomechanical environment. [74] (10.1016/j.jhsa.2018.11.020)
• [L5] Insertion of a correctly sized metallic radial head replacement recreates near normal biomechanics of the forearm with no change in the loading characteristics of the interosseous membrane. [77] (10.1302/0301-620x.95b10.31844)
• [L4] [84] (10.1016/j.jse.2010.08.012)
• [L4] Salvage of supracondylar non-union by means of a total elbow arthroplasty is a technically demanding procedure that should be done only when other therapeutic options are unsatisfactory. [87] (10.2106/00004623-198971070-00013)
• [L4] Ninety-four percent of patients engaged in moderate-demand activities after total elbow arthroplasty, and forty percent engaged in high-demand activities. [91] (10.1016/j.jse.2013.01.023)
• [L5] Overstuffing the radial head prosthesis alters joint kinematics and may lead to pain and degenerative changes. [92] (10.1177/1758573219881772)
• [L4] The valgus angulation of the available elbow designs is discordant with the mean native valgus angulation found in this study, and the valgus laxity of the implants does not cover the variability in the studied population. [95] (10.1016/j.jse.2023.04.017)
• [L5] The plane through the ridge of the GSN of a healthy proximal ulna could provide a more reliable anatomical landmark to estimate the position of the elbow FE axis compared to the posterior surface (95% CI range: 11°). [104] (10.1016/j.jseint.2024.10.016)
• [L5] Linking the Latitude total elbow prosthesis results in increased valgus stability. [106] (10.1016/j.jse.2013.02.010)
• [L4] [108] (10.1177/1758573214524934)
• [L4] The modified approach offers excellent exposure of the elbow joint, allows a solid repair of the triceps mechanism, and enables early mobilization after total elbow arthroplasty. [109] (10.1177/1758573214559319)
• [L4] [111] (10.1177/1758573216640210)
• [L5] [115] (10.1016/j.xrrt.2022.12.003)
• [L1] [117] (10.1186/s12891-019-2848-x)
• [L4] [119] (10.2106/00004623-198163070-00002)
• [L3] [120] (10.1177/17585732211043524)
• [L5] [126] (10.1016/j.xrrt.2022.02.004)
• [L4] [127] (10.5435/jaaos-21-07-427)
• [L2] [128] (10.1016/j.jhsa.2022.07.020)
• [L2] There is a lack of good quality evidence regarding the risks and benefits of venous thromboembolism prophylaxis in upper limb major joint replacement surgery. [129] (10.1177/1758573219896279)
• [L4] Total elbow arthroplasty for fracture in elderly patients provides pain relief, functional range of motion, and good patient-reported outcome scores. [130] (10.1016/j.jhsa.2020.10.034)
• [L5] [131] (10.1016/j.jhsa.2024.09.006)
• [L4] Patients with elbow arthroplasty had moderate pain, but limited grip strength and ROM, 1 year to 5 years after surgery. [135] (10.1111/j.1758-5740.2010.00081.x)
• [L4] The radial head arthroplasty diameter can be predicted preoperatively in two-thirds of cases from a simple measurement of the humeral condyle diameter with an appropriate lateral view of a simple radiograph. [137] (10.1016/j.jse.2018.01.017)
• [L3] Secondary total elbow arthroplasty after failed internal fixation has shown good functional results and a complication rate comparable to that of index total elbow arthroplasty in the treatment of articular fractures of the distal humerus in the elderly. [138] (10.1016/j.jse.2024.03.032)
• [L3] Heterotopic ossification after total elbow arthroplasty is seen more commonly than previously reported. [141] (10.1302/0301-620x.100b6.bjj-2017-0535.r2)
• [Abstract] The high rate of component loosening, which is of concern, may be related to the increased pathology and technical difficulty of elbow joint arthroplasty in the setting of prior failed internal fixation. [142] (10.1016/j.jse.2007.02.051)
• [L4] Primary arthroplasty as treatment of distal humeral fractures produces reliable results with regards to revisions and other adverse events. [146] (10.1016/j.jse.2018.07.035)
• [L3] Poor ulnar cementation may predict radiological loosening and eventual need for revision, but this loosening does not correlate with the patient's clinical outcomes. [147] (10.1016/j.jse.2021.03.063)
• [L1] The overall significant complication rate for modern total elbow arthroplasty is 24.3% ± 5.8%. [148] (10.1016/j.jse.2010.08.026)
• [L3] Complications occurred in 21% of patients undergoing total elbow arthroplasty and lead to a decrease in satisfaction and Oxford Elbow Score after 3 years, despite no significant differences at 1-year or 5-year follow-up. [149] (10.1016/j.jseint.2021.02.015)
• [L4] The overall interobserver reliability of radiographic assessment following press-fit bipolar RHA was poor among experienced elbow surgeons. [150] (10.1177/1758573217719088)
• [L3] We found acceptable implant survival rates after 5 and 10 years, with a higher revision rate for the unlinked design and primary TEA due to fracture sequelae. [151] (10.1016/j.jse.2014.02.001)
• [L5] Periprosthetic joint infection after total elbow arthroplasty is relatively common and difficult to eradicate, with prevention being key. [152] (10.1302/0301-620x.106b11.bjj-2024-0549.r1)
• [L3] The reduction in PJI seen in this IVP cohort has changed the practice of the authors, who now routinely administer vancomycin powder for total elbow arthroplasty. [153] (10.1016/j.xrrt.2025.06.013)
• [L3] Based on these results, and accepting the limitations of this registry study, we cannot recommend the use of SHSs as a means of infection prevention in primary elbow arthroplasty. [156] (10.1016/j.jse.2024.11.034)

References¶

[1] Primary elbow arthroplasty: problems and solutions. Shoulder & Elbow. 2016. DOI: 10.1177/1758573216677200

[2] Optimizing Outcomes in Total Elbow Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00473

[3] Kudo type-5 total elbow arthroplasty for patients with rheumatoid arthritis. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b6.bjj-2016-1033.r2

[4] Thirty-day Morbidity and Mortality after Elective Total Elbow Arthroplasty. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.07.007

[6] Triceps on approach for total elbow arthroplasty: worth preserving? A review of approaches for total elbow arthroplasty. Shoulder & Elbow. 2016. DOI: 10.1177/1758573216682479

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