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Elbow Arthroplasty

Total elbow replacement — indications, implants, and recovery.

142 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Total elbow arthroplasty is the most definitive functional procedure for end-stage painful arthritis of the elbow, with the primary goal of pain relief [8, 16]. Indications have expanded markedly over the past decade to address the sequelae of trauma rather than solely inflammatory conditions [34]. The procedure is now a surgical option for osteoarthritis, post-traumatic arthritis, and acute fractures, with total elbow arthroplasty for acute trauma and osteoarthritis becoming increasingly common [73, 36]. It remains a reliable treatment for elbows severely affected by rheumatoid arthritis, where recent reports demonstrate decreased complication prevalence, excellent pain relief, and functional restoration [11]. However, because there are no other options after replacement, total elbow arthroplasty should be considered a last step in rheumatoid arthritis patients [74].

Outcomes are contingent on strict patient selection and adherence to postoperative rehabilitation [45]. Age at surgery is a risk factor for complications, necessitating careful consideration of the indication in patients under 60 [18]. While total elbow arthroplasty may be performed in younger patients when no other alternatives exist, joint-preserving procedures for elbow arthritis are generally more successful than other surgical options for shoulder arthritis [30]. With careful selection, convertible total elbow arthroplasty provides good to excellent outcomes and substantial improvements in range of motion [38]. Lateral resurfacing elbow arthroplasty serves as a satisfactory alternative with lower complication rates and less restrictive activity limitations [37]. Concomitant total wrist and elbow arthroplasty is a viable option for selected patients with ipsilateral degenerative changes, offering reduced recovery time, lower costs, and decreased morbidity compared to two-stage procedures [80].

Despite its efficacy, total elbow arthroplasty remains associated with substantial complication and reoperation rates [9]. Patients undergoing elective total elbow arthroplasty have slightly higher complication rates than those undergoing shoulder, hip, or knee arthroplasty [7]. Survival rates remain low and complication rates remain high, yet are comparable to those of other elbow arthroplasties [75]. Complication and revision rates for joint replacement surgery for elbow tumours are also comparable to other indications [17]. Currently, there is insufficient evidence to identify the best type of elbow implant, with choice determined by surgeon preference, familiarity, and patient circumstances [19]. Although total elbow arthroplasty designs have evolved, long-term outcome data remain limited [6]. Continued success depends on advances in surgical planning, technique, implant design, and materials to make elbow arthroplasty as reliable and lasting as hip or knee arthroplasty [2, 3].

Anatomy & Pathophysiology

Bony Anatomy

The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that provide bony stability [109]. The ulnohumeral joint is formed by the articulation of the trochlea with the ulna within the greater sigmoid notch [109]. This articulation features highly congruent anatomy through almost 180° of articular contact, with the exception of a bare area in the greater sigmoid notch devoid of cartilage [109]. The radiocapitellar joint is formed by the articulation of the capitellum and the radial head [109]. The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [109]. The proximal radioulnar joint holds the radius in close approximation to the ulna via the annular ligament [109].

The distal humeral articulation is angled 30° from the longitudinal axis of the humerus [109, 53]. The axis of rotation of the elbow is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side positioned more distally than the lateral side [109]. The normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [53, 113]. In full extension, 60% of axial load is transmitted through the radiocapitellar joint [53, 113]. The ulna medially bends approximately 8° at 8 cm from the tip of the olecranon [109]. The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [109]. The distal humerus consists of medial and lateral columns [53, 113]. The articular surface of the distal humerus is angled 30 degrees anterior to the humeral shaft axis [53, 113].

Ligamentous Anatomy

Elbow stability is determined by primary stabilizers (ulnohumeral articulation, medial ulnar collateral ligament, lateral ulnar collateral ligament complex) and secondary stabilizers (radiocapitellar articulation, common flexor tendon, common extensor tendon, and joint capsule) [50]. The medial collateral ligament complex comprises the anterior oblique, posterior oblique, and transverse ligaments [123]. The anterior oblique ligament is the strongest component of the medial collateral ligament complex and serves as the primary stabilizer to valgus stress [123]. The anterior bundle of the medial collateral ligament originates on the anterior-inferior edge of the medial epicondyle and inserts on the sublime tubercle of the ulna [123, 53]. It is the primary restraint to valgus stress within functional elbow range of motion [53, 113]. The posterior bundle of the medial collateral ligament is the primary restraint to valgus stress with the elbow in maximal flexion [53, 113]. Stability in full extension is provided by the medial collateral ligament, joint capsule, and ulnohumeral articulation [53, 113]. The lateral ulnar collateral ligament complex originates at the geometric center of the radiocapitellar articulation, just distal to the lateral epicondyle [109]. The radial head acts as a secondary restraint to valgus stress [53, 113].

Kinematics and Biomechanics

The normal range of elbow flexion/extension is 0 to 150 degrees [53, 113]. The normal range of forearm pronosupination is 80 to 85 degrees in each direction [53, 113]. The functional range of motion for the elbow is defined as a 100° flexion/extension arc (30° to 130° of flexion) and a 100° pronation/supination arc (50° of supination and 50° of pronation) [202]. The ulnohumeral joint allows for flexion and extension of the elbow [54]. The radiocapitellar joint allows for forearm rotation [54]. Shoulder abduction results in a varus moment at the elbow [126]. Valgus torque generated at the elbow during throwing maneuvers is highest in the late cocking and early acceleration phases of throwing [123, 62].

Pathophysiology of Arthritis

Symptomatic primary osteoarthritis of the elbow affects 2% of the population [33]. The average age of presentation for primary elbow osteoarthritis is 50 years, with a range of 20 to 70 years [33]. Men are affected by primary elbow osteoarthritis more often than women at a 4:1 ratio [33]. Hand dominance and strenuous manual labor are associated with primary osteoarthritis of the elbow [33]. Secondary causes of elbow osteoarthritis include trauma, osteochondritis dissecans, and synovial osteochondromatosis [33]. Elbow osteoarthritis is characterized by osteophyte formation, capsular contracture, and loose bodies, often with relative preservation of the joint space [33]. Periarticular hypertrophic osteophytes act as a mechanical block at the end ranges of flexion and extension in elbow osteoarthritis [33]. Elbow osteoarthritis typically involves the radiocapitellar joint articular cartilage preferentially, with relative preservation of the ulnohumeral articular surfaces [33]. Ulnar neuropathy is present in up to 50% of patients with elbow osteoarthritis [33]. In valgus extension overload syndrome, the olecranon is repeatedly driven into the olecranon fossa during throwing, exerting shear forces that may cause cartilage injury and osteophyte development [62]. The pathoanatomy of valgus extension overload syndrome includes chondrosis, osteophyte development on the posteromedial olecranon and humerus, and loose bodies [62]. Olecranon resection increases valgus angulation and medial collateral ligament strain during valgus stress [62].

Pathophysiology of Instability and Injury

Elbow dislocations occur when loads placed on the structures about the elbow exceed the intrinsic stability provided by the anatomic shape of the joint surfaces and soft-tissue constraints [58]. Posterior dislocations are the most common type of elbow dislocation, accounting for 80% of cases [58]. Both collateral ligaments are disrupted in posterior elbow dislocations, whether posteromedial or posterolateral [58]. The lateral ulnar collateral ligament injury is the cause of recurrent instability following elbow dislocation [58]. An elbow dislocation associated with a fracture of the coronoid process increases the risk of recurrent and chronic instability [58]. The "terrible triad" of the elbow consists of an elbow dislocation with radial head and coronoid fractures [58]. The most common problems following treatment of the terrible triad are recurrent and chronic instability, stiffness, posttraumatic arthrosis, and pain [58]. The olecranon stabilizes valgus stress to the elbow, and excessive resection places the medial collateral ligament at risk [123]. Surrounding elbow musculature, specifically the flexor digitorum superficialis and flexor carpi ulnaris, provides a dynamic stabilizing force across the elbow joint that may protect the static restraint of the medial collateral ligament [123].

Classification

Copenhagen Classification for Distal Humeral Fractures (CCDHF): This system distinguishes fractures that may not be suitable for open reduction and internal fixation (ORIF) and require treatment with elbow hemiarthroplasty (EHA) or total elbow arthroplasty (TEA) [223]. Its primary objective is to identify patients who may require hemi- or total elbow arthroplasty [223]. The CCDHF was compared for inter- and intra-observer agreement against the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) and Sheffield classification systems [223].

Mayo Classification: This system categorizes periprosthetic fractures in total elbow arthroplasty based on bone and implant status [226].

Goldberg Classification: This system assesses radiographic loosening of total elbow arthroplasty components [220]. Radiographic findings for prosthetic loosening are graded as type 0 (radiolucent line <1 mm thick, <50% interface), type I (≥1 mm thick, <50% interface), and type II (>1 mm thick, >50% interface) [83].

Larsen Classification: This system grades the severity of rheumatoid arthritis in the elbow [81].

American Rheumatoid Association Classification: This system assesses the functional severity of rheumatoid arthritis disease [79].

American College of Rheumatology Criteria: These criteria are used for the classification of rheumatoid arthritis [230].

Clinical Presentation

History and Symptoms

Patients with primary osteoarthritis of the elbow typically present with loss of terminal extension and flexion, accompanied by painful catching, clicking, or locking [33]. Pain is characteristically noted at the end ranges of motion rather than through the midrange [33]. Night pain is not typical for primary osteoarthritis; if present, an inflammatory cause should be considered [33]. A thorough history and physical examination are invaluable for understanding the disease process and its impact on the patient [209]. Determining whether pain occurs throughout the arc of motion or only at terminal limits is of paramount importance [209]. The location, quality, context, duration, and severity of elbow pain help focus the physical examination and understand pathology [210]. Prior treatments, including surgical interventions and injections, aid in making the correct diagnosis [210]. Determining the symptom trajectory—whether pain is improving, worsening, or constant—is extremely helpful when considering intervention [210]. Associated mechanical symptoms or instability must be evaluated during the clinical presentation assessment [209]. Associated conditions such as cubital tunnel syndrome must be considered and evaluated to provide optimal management recommendations [209].

Physical Examination

The fundamental elements of the elbow examination include inspection, palpation, range of motion, strength, stability, and special tests [210]. Range of motion assessment should include active and passive flexion, extension, supination, and pronation [29]. A goniometer should be used for accurate measurement, and the contralateral elbow should be examined for comparison [29]. Pain should be assessed during the mid-arc or at the terminal ends of motion [29]. Mid-arc range of motion pain is more common with intrinsic disease and may not improve with contracture release alone [29]. Loss of full extension is the first motion altered by most pathology and the last to be regained [207]. 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 [207]. Rupture of the triceps tendon or neurologic conditions should be suspected if there is loss of active extension [207]. Loss of passive extension is a sensitive but nonspecific sign of an intra-articular process [207]. The simple extension test has a sensitivity of 97% and a negative predictive value of 98% [207]. The specificity of the simple extension test is 69%, with a positive predictive value of 63% [207]. Any significant difference between active and passive ranges of motion suggests pain or motor dysfunction as the cause [207].

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 [207]. The upper extremity should be examined from the side with the hand in full supination to adequately assess for contracture [207]. A careful assessment of any compromised motion at the shoulder or wrist is required, as disability often arises from a combination of factors [207]. Flexion contractures of less than 45° may have little practical significance, although patients may be concerned about cosmetic appearance [207]. To perform 90% of required daily activity, 50° of pronation and supination are required [207]. Pronation is the most important function on the dominant side for eating and writing, and loss of pronation is compensated by shoulder abduction [207]. Loss of supination on the nondominant side may significantly hinder personal hygiene needs, accepting objects, and opening door handles [207]. The radial head is driven into the capitellum with pronation by the screw-home mechanism [207]. Reproduction of radiocapitellar pain with the radiocapitellar load test signals a problem with the joint [207]. Crepitus can be noted with the radiocapitellar load test maneuver [207]. 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 [29].

Ulnar neuropathy is present in up to 50% of patients with primary osteoarthritis of the elbow [33]. The ulnar nerve is of utmost importance during examination because of its anatomic proximity to the elbow [29]. An assessment for ulnar nerve subluxation should be performed, as subluxation is a relative contraindication for arthroscopic procedure secondary to possible iatrogenic nerve injury [29]. Electromyography and nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists [29]. Electromyography and nerve conduction studies may be useful to evaluate the degree of nerve compression and contribution to elbow pain or dysfunction [209].

Imaging

Standard AP, lateral, and oblique radiographs are standard for elbow evaluation [29]. 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 [29]. Radiographs typically show osteophyte formation at the coronoid process (anterior and medial), coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa in primary osteoarthritis [33]. Joint spaces at the ulnohumeral joint are usually preserved in primary osteoarthritis [33]. Joint spaces at the radiocapitellar joint are mildly narrowed in primary osteoarthritis [33]. Loose bodies may be evident on radiographs, which typically underestimate the number present [33]. Serial radiography is used as follow-up when heterotopic ossification is present [29].

CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [29]. Three-dimensional CT is used to check for heterotopic ossification [29]. CT is not necessary when stiffness is entirely soft-tissue related [29]. CT scans with 3D reconstructions may be useful for evaluating the extent and location of disease and for surgical planning [209]. MRI can be used to evaluate ligaments and tendons, but it is rarely indicated [29]. MRI may be useful to evaluate the status of soft tissues including the medial and lateral collateral ligamentous complexes [209].

Investigations

History and Physical Examination

The history for elbow stiffness must document the duration of the contracture, initial injury, previous surgical procedures, trials of splinting, therapy, or injections, surgical complications, and the patient’s work, life demands, and goals [29]. Physical examination requires assessment of upper extremity function across the shoulder, wrist, and hand, alongside inspection of soft tissues for previous skin incisions, grafts, eschar, or infection [29]. Range of motion assessment must include active and passive flexion, extension, supination, and pronation using a goniometer, with the contralateral elbow examined for comparison [29]. Pain assessment during range of motion should distinguish between mid-arc pain, which is more common with intrinsic disease, and terminal end pain [29].

The ulnar nerve is of utmost importance in the neurovascular examination due to its anatomic proximity to the elbow and the posterior bundle of the medial collateral ligament forming the floor of the cubital tunnel [29]. Electromyography and nerve conduction velocity studies should be performed if there is any question about neurologic dysfunction [29]. If a history of prior surgical procedures exists, it must be verified whether the ulnar nerve has been transposed [29]. A complete neurovascular examination of the radial, median, ulnar, and anterior and posterior interosseous nerves should be done before and after treatment for elbow injuries [54]. Neurovascular status should be documented both before and after elbow reduction for acute dislocations [127]. Open injuries and compartment syndrome, which require immediate surgical treatment, should be ruled out during the physical examination of acute elbow dislocations [127].

Patients with primary osteoarthritis of the elbow typically present with loss of terminal extension and flexion and painful catching, clicking, or locking [33]. Pain in primary osteoarthritis of the elbow is typically noted at the end ranges of motion rather than through the midrange [33]. The presence of night pain in elbow arthritis suggests an inflammatory cause rather than typical osteoarthritis [33]. Forearm rotation is relatively preserved until later in the disease process of primary osteoarthritis [33]. Inspection for primary osteoarthritis should check for prior surgical incisions and joint effusion at the lateral soft spot [33]. The degree of disability caused by osteoarthritis depends on the patient’s vocation and physical disability and should be determined during evaluation [33].

Imaging

Plain radiography: Standard radiographs for the elbow include AP, lateral, and oblique views, with serial radiography used as follow-up when heterotopic ossification is present [29]. Primary bony landmarks identified on elbow radiographs include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [29]. Radiographs for primary osteoarthritis typically show osteophyte formation at the coronoid process (anterior and medial), coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa [33]. In primary osteoarthritis, joint spaces at the ulnohumeral joint are usually preserved, while those at the radiocapitellar joint are mildly narrowed [33]. Radiographs typically underestimate the number of loose bodies present in the elbow [33]. Plain AP and lateral radiographs are necessary to document congruent reduction after elbow dislocation [127]. Oblique views may be useful to identify periarticular fractures in elbow dislocations [127]. Postreduction radiographic assessment (AP and lateral views with the elbow at 90° and appropriate forearm rotation) is performed to confirm concentric reduction, ensuring a concentric ulnohumeral reduction and alignment of the radial head with the capitellum [127]. AP, lateral, oblique, and axillary views of the elbow may reveal posteromedial olecranon osteophytes and/or loose bodies in valgus extension overload syndrome [62]. Radiographic evaluations are essential when diagnosing an osteochondritis dissecans lesion of the elbow [128]. Plain radiographs are still most often employed for medial epicondyle fractures, though oblique and axial views have been proposed to improve measurement accuracy of displacement [138]. Plain radiographs of the elbow can potentially show widening of the apophysis or fragmentation of the medial epicondyle in Little Leaguer’s elbow [137]. Comparison views can be useful in the diagnosis of Little Leaguer’s elbow [137].

CT: CT is helpful for assessing malunion architecture and the location and pattern of osteophytes or loose bodies [29]. CT is not necessary when elbow stiffness is entirely soft-tissue related, but is beneficial if joint incongruity or abnormal bony anatomy is present [29]. CT may be useful for surgical planning in primary osteoarthritis by allowing a detailed assessment of osteophytes and the presence of loose bodies [33]. CT is useful to identify associated osseous injury in elbow dislocations [127]. With an incongruous reduction of the elbow, CT or MRI should be considered to identify potential incarcerated osteocartilaginous fragments [127]. CT can be helpful in identifying mineralized intra-articular loose bodies or delineating the anatomy of a complex intra-articular fracture [124]. CT scan with three-dimensional reconstruction is helpful for preoperative planning of intercondylar fractures [54]. CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [62].

MRI: MRI can be used to evaluate ligaments and tendons but is rarely indicated for elbow stiffness [29]. MRI is the imaging modality best suited for evaluating soft-tissue structures in the elbow including ligaments, tendons, cartilage, and nerves [124]. Conventional MRI sequences should be obtained in all three planes using T1-weighted and fluid-sensitive sequences (short tau inversion recovery or T2-weighted sequences with fat suppression) [124]. Magnetic resonance arthrography is particularly beneficial in the evaluation of osteochondral lesions, loose bodies, and ulnar collateral ligament injury in a throwing athlete [124]. Coronal MRI studies should be obtained along a line connecting the medial and lateral epicondyles, and sagittal studies should be perpendicular to the coronal studies [124]. 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 [124]. Caution is necessary with 3-Tesla imaging because it can show mild signal alterations of tendons, ligaments, and nerves of the elbow that may not be symptomatic [124]. Ligaments and tendons appear anechoic (black) on all MRI imaging sequences [124]. With tissue remodeling or degeneration, the signal increases on all MRI sequences [124]. Tears are diagnosed on MRI by identifying signal in the tissue that brightens to the level of simple fluid, representing focal discontinuity of tendon or ligament fibers [124]. Partial tears on MRI are described by identifying whether the involved pathology occurs at the articular side, intrasubstance, or involves superficial fibers [124]. Both partial-thickness and full-thickness tears on MRI should identify whether failure occurs proximally, mid-substance, or distally [124]. MRI may be most helpful in evaluating associated injuries including partial or complete tears of the medial collateral ligament in valgus extension overload syndrome [62]. Important aspects of osteochondritis dissecans lesions may be better seen with MRI [128]. MRI of the elbow and the upper extremity athlete may be employed or used to identify partial or periosteal sleeve avulsions of the medial epicondyle [138]. MRI studies in symptomatic youth athletes with Little Leaguer’s elbow often show edema at the distal humerus or medial epicondyle apophysis [137]. Preseason MRI abnormalities in youth baseball players were associated with year-round play, private coaching, and loss of shoulder internal rotation [137]. Postseason MRI evaluation of dominant elbows revealed abnormalities in 46% of Little League players [137].

Ultrasonography: Ultrasonographic soft-tissue evaluation in the elbow is most useful in evaluating the distal biceps and the common flexor and extensor tendons [124]. Ultrasonography allows dynamic imaging, which may be useful in evaluating for ulnar nerve subluxation or a snapping triceps [124].

Other Considerations: Radiographs, CT, ultrasonography, and MRI each have a role in elbow imaging [124]. Pre-operative templating using plain elbow radiographs does not add benefits in pre-operative decision making for total elbow arthroplasty [253]. 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 [233]. If a radial head prosthesis is used, prosthesis oversizing should be avoided as it may contribute to worse outcome with other radiographic abnormalities [255]. The overall interobserver reliability of radiographic assessment following press-fit bipolar radial head arthroplasty was poor among experienced elbow surgeons [251].

Surveillance and Follow-up: Long-term surveillance of primary linked total elbow arthroplasty has higher efficacy than primary shoulder arthroplasty, supporting appropriate resource allocation for elbow arthroplasty surveillance [24]. The Discovery elbow replacement demonstrates early clinical results similar to other semi-constrained total elbow replacements, with continued radiological surveillance warranted for humeral lucency [22]. Many patients with the iBP elbow prosthesis have radiolucencies, and the discrepancy between clinical signs and radiological results warrants structural follow-up [270]. Poor ulnar cementation may predict radiological loosening and eventual need for revision, but this loosening does not correlate with the patient's clinical outcomes [247]. Increased incidence of radiolucent lines around the ulnar stem and bushing wear with longer follow-up is of concern and represents the failure mode for the Coonrad/Morrey total elbow arthroplasty implant [262]. There is concern about early radiologic loosening of the radial component in Latitude primary total elbow replacement, though this has not resulted in clinical symptoms or implant failure yet [232]. Further follow-up is required to investigate the radiological changes observed in some patients with semiconstrained total elbow arthroplasty for rheumatoid arthritis [261].

Treatment

Non-Operative

Nonsurgical management may provide relief in early stages of elbow arthritis [32]. Osteocapsular debridement is an effective surgical treatment option for patients with symptomatic primary elbow osteoarthritis who have failed conservative management [212, 213].

Operative

Indications: The primary indications for total elbow arthroplasty are pain and/or instability [89]. Deformity and dysfunction without pain are not indications for surgery [89]. An unreconstructible distal humeral fracture in an elderly patient is an increasingly common indication [89]. Rheumatoid arthritis with radiographic evidence of joint destruction too advanced to benefit from radial head excision and synovectomy is generally considered an indication [89]. Elderly patients with end-stage posttraumatic sequelae are acceptable candidates [89]. Bony or fibrous ankylosis with the elbow in a poorly functioning position is an indication [89]. The range of indications is broadening, with total elbow arthroplasty for acute trauma and osteoarthritis becoming increasingly common [36]. Treatment of elbow arthritis must be individualized based on etiology, severity, patient age, and functional demands [32]. A stable, painless elbow with preservation of motion in the middle or functional range usually does not require arthroplasty [89]. Total elbow arthroplasty is a recognized and preferable option compared with synovectomy or interpositional arthroplasty for most patients with rheumatoid arthritis [136]. Total elbow arthroplasty is an effective treatment for end-stage arthritis, with results in rheumatoid arthritis appearing nearly as free of complications as those performed for other indications [74]. Total elbow arthroplasty should be considered a last step due to the lack of other options after replacement [74]. Elbow arthroplasty is very successful in terms of pain relief, motion, and function [12]. Total elbow arthroplasty provides a successful early outcome for most elderly patients with comminuted distal humerus fractures [27]. Direct comparisons between internal fixation and arthroplasty for selected elderly patients with distal humerus fractures have shown better outcomes with arthroplasty [27]. Total elbow arthroplasty can be a valid alternative for complex distal humerus fractures in elderly patients with moderate functional demands [134]. Total elbow arthroplasty for distal humerus fractures provided similar clinical and functional outcomes when performed as a primary procedure or after failed internal fixation [86]. 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 ORIF or nonsurgical management [92]. Unlinked, noncongruous elbow arthroplasty can be a successful alternative in the management of acute distal humeral fractures when internal fixation is not a viable option [151]. Total elbow arthroplasty for fracture in elderly patients provides pain relief, functional range of motion, and good patient-reported outcome scores [225]. When successful, total elbow arthroplasty provided adequate pain relief and good functional restoration for post-traumatic sequelae after proximal ulna or radius fracture and fracture-dislocations [91]. Total elbow arthroplasty remains an alternative to osteosynthesis with very satisfactory immediate results restoring a painless, stable, and functional elbow in traumatology [169]. 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 [157]. Total elbow arthroplasty 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 [90]. Total elbow arthroplasty may be performed in younger patients for whom no other alternatives are available [30]. Joint-preserving procedures for elbow arthritis are generally more successful than other surgical options for shoulder arthritis [30]. The age at surgery is a risk factor for complications, and the indication for total elbow arthroplasty in patients under 60 should be carefully considered [18]. Higher demand, male gender, trauma-related, and young age have consistently been linked to poorer outcomes and higher risk of revision following total elbow arthroplasty [88].

Surgical Approach / Technique: The selection of the surgical exposure to the elbow rests on three considerations: the pathology being treated, prior surgery, and the surgeon's preference and experience [217]. Elbows with distal humeral bone loss (acute distal humeral fracture, distal humeral nonunion, some revision cases) may be best managed by leaving the triceps attached [217]. It is wise to be comfortable with more than one means of exposure, as both pathology and implant design may prompt modifications from the preferred technique [217]. Management of the triceps is guided by the underlying pathology, implant type, and surgeon preference [216]. The main types of approach used in TEA are triceps-splitting, -reflecting, and -sparing [216]. 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 [216]. The latter triceps-splitting approach allows for lengthening of the extensor mechanism in cases of extension contracture [216]. The triceps-reflecting (ie, Bryan-Morrey) approach has traditionally been used for elbow replacement [216]. In the Bryan-Morrey approach, the triceps is reflected from medial to lateral in continuity with the anconeus muscle [216]. At the conclusion of the Bryan-Morrey surgery, the triceps is reattached to the ulna through cruciate tunnels using nonabsorbable suture passed through the triceps tendon [216]. An additional horizontal tunnel allows passage of suture to cinch the triceps securely to the olecranon to prevent synovial fluid extravasation behind the repair [216]. 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 [216]. A triceps-sparing approach has been advocated for TEA to manage acute fracture of the distal humerus [216]. Removal of the distal fracture fragments helps to maintain the triceps and achieve adequate exposure for component implantation in a triceps-sparing approach [216]. The procedure for total elbow arthroplasty in distal humerus fractures typically involves resection of the fractured fragments, which allows implantation of the components without violation of the extensor mechanism [27]. The review discusses various approaches to total elbow arthroplasty and their reported outcomes to assist surgeons in making an informed choice [14]. The Van Gorder approach is the largest study evaluating this specific surgical approach to the elbow for primary TEA with an average follow-up of 32 months [65]. 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 [131]. The medial single-window approach ensures sufficient visualization for total elbow arthroplasty while minimizing postoperative complications and allowing early safe mobilization [132]. The triceps fascial tongue exposure provides an excellent view of the joint while causing minimal trauma to the extensor mechanism facilitating tendon healing [208]. The triceps fascial tongue exposure allows easy intraoperative conversion from fracture fixation to a total elbow arthroplasty if a fracture is not able to be reconstructed [208]. In a case series of 30 total elbow arthroplasties using the triceps fascial tongue exposure, there were no triceps-related failures [208]. The "global" approach allows circumferential exposure of the elbow, reaching the collateral ligaments, coronoid process, and anterior joint capsule [56]. In the global approach, a straight posterior midline incision is made [56]. If the medial aspect of the elbow is to be exposed in the global approach, the cubital tunnel is opened, the ulnar nerve is isolated, and it is transposed anteriorly [56]. 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 [56]. To expose the olecranon fossa and posterior aspect of the distal humerus in the global approach, the anconeus and triceps are reflected medially [56]. 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 [56]. 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 [56]. If additional exposure of the radial head is needed in the global approach, a chevron osteotomy of the lateral epicondyle is performed [56]. To extend the global approach medially, the flexor carpi ulnaris and flexor digitorum profundus muscles are released subperiosteally from their ulnar origins [56]. 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 [56]. Bryan and Morrey developed a modified posterior approach to the elbow.

Implant Selection: 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 [89]. 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 [89]. 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 [89]. The semiconstrained TEA 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 [88]. The loose coupling of the humeral and ulnar components in semiconstrained TEA allows 7 degrees of varus–valgus and 7 degrees of axial rotation enabling forces to be dissipated through the capsule and ligaments [88]. Clinical success and technical simplicity have led to the popularity of the semiconstrained design [88]. Convertible models allow simpler conversion from unconstrained to semiconstrained implants [88]. Convertible prostheses may provide a solution when elbow stability can be determined intraoperatively, with recent long-term results described as promising [85]. Within the follow-up limitations of a 2000 report, semiconstrained and unconstrained elbow prostheses seem equally durable [84]. A systematic review in 2005 showed 78% good–excellent results for TEA, which were more common for semiconstrained implants (82%) versus unlinked (78%) versus fixed hinge (73%) [88]. A 2011 study suggested an overall 24.3% complication rate which was slightly lower for linked (25.9%) versus unlinked (27.2%) prostheses [88]. Linked implants did not have higher clinical loosening (5.2%) compared with unlinked (5.2%) in a 2011 study [88]. Clinical instability was lower in linked (1.4%) versus unlinked (4.9%) implants in a 2011 study [88]. A recent review showed decreased aseptic loosening of linked compared with unlinked (p < 0.005) prostheses [88]. Revision was lower for linked (13.8%) versus unlinked (16.3%; p = 0.015) in a recent review [88]. Unlinked implants were introduced to better restore normal elbow mechanics and rely on intact capsuloligamentous restraints for stability and function [88]. Unconstrained models promise to dissipate forces through the ligaments and capsule, shielding the cement–bone interface, aiming to lower aseptic loosening [88]. 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 [88]. Initial "fixed-hinge" designs were plagued with failure because the hinges were fully constrained allowing <1 degree of varus–valgus laxity [88]. Fully constrained implants failed to restore physiologic mechanics to the elbow and transferred profound forces through the bone–implant interface [88]. Coupled with primitive cementation techniques, fully constrained implants were plagued with high loosening rates [88]. 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 [51]. The review focuses on the evolution of the elbow arthroplasty, from a historic overview, up to the present and addresses issues that could improve the clinical outcome in today's practice [10].

Other Considerations: The goal of treatment for post-traumatic osteoarthritis of the elbow is to obtain a low level of pain with sufficient motion range to ensure good function, while preserving future surgical options and delaying elbow arthroplasty to the extent possible [1]. The goals of reconstructive elbow surgery are to restore function through pain relief and restoration of motion and stability [89]. In most cases, elbow function was maintained in the long-term without loosening of the implant in patients with rheumatoid arthritis treated with Kudo type-5 total elbow arthroplasty [5]. 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 [32]. Interposition arthroplasty can improve elbow motion and function but at the expense of elbow stability despite hinged external fixation [43]. Elbow arthrodesis is reserved for patients with painful arthritis who are not candidates for total elbow arthroplasty, especially individuals who place high demands on the upper extremities, such as manual laborers [87]. Total elbow arthroplasty, fascial arthroplasty, or even resection arthroplasty in the presence of functional musculature often provides better function of the upper extremity than does elbow arthrodesis [87]. Elbow fusion is indicated for persistent infection, including tuberculosis [87]. Elbow arthrodesis has become recognized as the optimal treatment for massive upper extremity trauma seen on the battlefield [87]. For unilateral arthrodesis of the elbow, a position of 90 to 100 degrees of flexion is desirable to provide the most powerful grip strength [87]. If bilateral elbow arthrodesis is indicated, one elbow should be placed in 110 to 120 degrees of flexion to permit the patient to reach the mouth, and the other should be placed in 45 to 65 degrees to aid in personal hygiene [87].

Complications

Overall Rates and Reoperation: Total elbow arthroplasty (TEA) carries a high burden of morbidity, with overall complication rates reported up to 43%, including an 18% revision rate and 15% permanent complications [48]. A recent meta-analysis cites a 13.5% revision rate [48], while the overall significant complication rate for modern TEA is 24.3% ± 5.8% [248]. Complications occur in 21% of patients, leading to decreased satisfaction and Oxford Elbow Scores at three years [249]. In a cohort of 1,146 arthroplasties, fracture sequelae carried a relative risk of revision six times higher than inflammatory arthropathy [47]. Revision TEA is now required in up to one-third of cases within the first decade [26]. Specific implants show variable outcomes; Latitude primary TEA survival remains low with high complication rates comparable to other designs [75], while Nexel TEA exhibited unusually high complication and revision rates, mainly at the humeral component [256]. In rheumatoid arthritis, complication rates vary from 14% to 80% (median 33%) [115], with a German series of over 170 cases recording a 34.4% rate [115]. At the Mayo Clinic, 55% of procedures resulted in complications [203]. In post-traumatic settings, 53% of patients after index intra-articular distal humerus fracture showed at least one complication [119], with numerically higher rates after secondary TEA (69%) versus primary TEA (43%), though not statistically significant [119]. Secondary TEA after failed internal fixation shows complication rates comparable to index TEA for articular fractures in the elderly [234]. In US university centers, inpatient complication rates are low (DVT 0.8%, re-operation 0.5%, infection 0.4%), with a 4.4% 30-day readmission rate [206]. Tumor-related elbow replacement complication and revision rates are comparable to other indications [17]. Lateral resurfacing elbow arthroplasty has lower complication rates than total elbow arthroplasty [37].

Infection (PJI): Periprosthetic joint infection (PJI) is a dreaded complication with an incidence of 0% to 11.5% (average 5–6%) [48]. TEA carries a higher infection risk than other major joint replacements [42], particularly in patients with rheumatoid arthritis compared to posttraumatic sequelae [48]. Persistent wound drainage is highly indicative of deep infection and predicts component resection [48]. PJI is relatively common and difficult to eradicate, making prevention key [257]. Two-stage revision is the most effective treatment, showing the lowest recurrence rate [278]. Shoulder and elbow PJI may be on a temporal decline [103]. Surgical helmet systems do not reduce PJI incidence [274]. Routine administration of vancomycin powder is now practiced by some authors following observed reductions in PJI [263]. In a systematic review of surgical revisions, no mortality events were associated with the revision strategy [201]. Non-infection related adverse event rates were 16.7% (95% CI: 3.0–56.4) for one-stage revision and ranged from 11.8% (95% CI: 4.7–26.6) to 20.0% (95% CI: 3.6–62.4) for two-stage revision [201]. Additional surgery for non-infectious reasons was performed in 44% of elbows free of infection following two-stage reimplantation [101]. In a two-stage reimplantation study, the mean interval between index TEA and resection was 7 years (range 0.14–37 years) [97]. PJI was categorized as acute (within 3 months, 1 elbow), subacute (3 months to 1 year, 9 elbows), and chronic (>1 year, 42 elbows) [97]. One component was retained in 17% of elbows, while all components were resected in the remaining 83% [97]. Elbow arthrodesis is not recommended as a salvage procedure for failed TEA with deep infection due to difficulty achieving solid fusion and increased complication rates [279].

Aseptic Loosening: Aseptic loosening is the most prevalent reason for revision (38%) in a systematic review of 9,308 TEAs [96]. It is a principal complication of unconstrained TEA, usually involving the humeral component [48]. For semiconstrained prostheses, humeral loosening has been reduced by design improvements, operative technique changes, and better anatomical understanding [48]. Use of a shorter (4-inch) stem in semiconstrained TEA resulted in earlier time to revision than longer (6-inch) stems [48]. Humeral stem loosening remains uncommon at approximately 2% at an average of 7 years follow-up [48]. Ulnar component loosening and osteolysis increased with the addition of a polymethylmethacrylate precoat in the 1990s but decreased after the surface finish changed to plasma spray [48]. All unnotched group aseptic loosening cases occurred at the bone-cement interface within 2 years [246]. In the Kudo prosthesis, the ulnar component is more commonly affected by aseptic loosening and malalignment [115]. High rates of component loosening may relate to increased pathology and technical difficulty in patients with prior failed internal fixation [238]. In young patients with Coonrad-Morrey TEA, progressive humeral radiolucent lines were found in 14% [63], ulnar radiolucent lines in 6% [63], low-grade humeral radiolucency in 31% [63], and nonprogressive ulnar radiolucent lines in 12% [63]. Mechanical loosening may be associated with fracture, bone resorption, or cortical expansion, perforation, or thinning [121]. When bone loss is moderate with cortical perforation, a standard long-stem implant may bypass defects [121]. In a series of 33 revision TEAs, moderate or severe bone loss was noted in 29 elbows [121]. After a minimum of 3 years follow-up, 55% had a good result and 45% had a poor result; another revision was performed in the poor-result group, with 8 eventually achieving a good result [121]. In a series of 41 revision TEAs, bone loss was grade-II in 19 elbows, grade-III in 9, and grade-IV in 13 [121]. In a study of the Pritchard ERS prosthesis, 14 failures occurred at an average of 81 months (range 1–159) [120]. Partial revision was done in 15 cases, implant removal in 5, and complete revision with another prosthesis in 9 [120]. At the Mayo Clinic, revisions were performed in 24% of elbows, with 11 due to loosening and 7 due to deep infection [203]. Follow-up revealed radiolucency in 29 elbows: 25 around the humeral and 4 around the ulnar component [203]. Inferior implant survivorship was demonstrated in TEA of the dominant versus nondominant elbow, conferring a 4.5-fold relative risk of revision [254]. Acceptable implant survival rates were found after 5 and 10 years, with higher revision rates for unlinked designs and primary TEA due to fracture sequelae [252]. Results of revision at a minimum of two years were inferior to those of primary capitellocondylar TEA [59].

Instability: Instability, in the form of dislocation or subluxation, is the most common complication requiring revision of unconstrained prostheses, occurring in 9% to 10% of TEAs [48]. True dislocation occurs in fewer than 5% of unlinked implants and is dependent on surgical technique [48]. Appropriate tensioning of the medial and lateral ligament complexes and preservation of the anterior capsule and triceps help avoid dislocation [48]. Aseptic loosening and instability remain the predominant causes for unlinked prosthesis revision [26]. Complications for linked prostheses are driven by high torsional stresses at the bone-cement interface and wear-related debris generation [26].

Nerve Palsy: Ulnar neuritis and triceps insufficiency are the most commonly encountered complications [48]. Nerve paresthesias occur in 11% of TEA cases, rarely requiring surgery [48]. Nerve entrapment occurs in 3% of cases, usually requiring surgery [48]. Postoperative nerve injury is a common and clinically important complication of revision TEA, affecting approximately one in five cases [26]. The ulnar nerve is most frequently involved, although radial nerve injury accounts for a substantial proportion [26]. Many neuropathies improve during follow-up, but persistent deficits and the need for secondary nerve-related procedures are not uncommon [26]. Radial nerve palsy is an uncommon complication after humeral revision, occurring in 2.7% of cases [154]. Only 43% of patients regained function after radial nerve palsy following humeral revision [154]. No recovery was observed in 4 out of 5 patients in whom power instruments or ultrasound was used for cement removal during humeral revision [154]. Two of three patients who underwent exposure of the radial nerve had return of function at most recent follow-up [154]. Formal exposure and protection of the radial nerve are predictive of recovery from radial nerve palsy after humeral revision [154]. A 3% incidence of significant ulnar nerve complications after TEA compares favorably with systematic reviews [222]. Transient neuropathy of the ulnar and posterior interosseous nerves was the most commonly reported neurological complication in radial head arthroplasty, occurring in 4.73% of cases [183]. In the majority of these cases, symptoms resolved spontaneously with no residual disability [183]. Only two reported cases required transposition of the ulnar nerve after radial head arthroplasty [183]. At the Mayo Clinic, 11 complications were ulnar neuropathies (two permanent and nine transient) [203].

Wound Complications: Wound problems occur in 14% of TEA cases, rarely requiring surgery [48]. Triceps problems occur in 4% of cases, usually requiring surgery [48]. Ankylosis occurs in 4% of cases, usually requiring surgery [48]. The overall incidence of soft tissue wound complication was 5.5% in a study of 1,749 replacement procedures [64]. In a study of early postoperative wound complications, 81% of patients had a history of elbow surgery in the affected limb, while 18% did not [64]. Obesity adversely influences the performance of elbow replacement after primary TEA [95]. The age at surgery is a risk factor for complications.

Polyethylene Wear: Wear of the polyethylene bearing surface accounts for a minority of revision procedures after TEA [48]. Factors associated with bushing wear include younger patient age, male sex, posttraumatic arthritis, preoperative elbow deformity, supracondylar nonunion, and high activity levels [48]. Implant malalignment has been implicated in a biomechanical model for bushing wear [48]. 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 [48]. Osteolytic reaction similar to that seen in total hip and knee replacements has been found in total elbow replacement [48]. 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 [48]. Polyethylene particles, cement, and metal debris were all found at the time of total elbow revision [48]. Osteolysis in TEA is a multifactorial process [48].

Other Considerations: Revision of a TEA presents major problems to the surgeon due to poor bone quality, previously violated soft-tissue planes, and risk to peripheral nerves [67]. Revision is performed most frequently for septic or aseptic loosening or for dislocation [67]. Bone quality and loss are critical factors in determining revision strategy for failed TEA [44].

Recovery

Light activity (weeks): The evidence provided does not specify a typical week range for light activities such as desk work, driving, or light activities of daily living.

Full activity (months): The evidence provided does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The evidence provided does not specify a month range for when pain, strength, and final functional outcomes stabilise.

Rehabilitation protocol: The modified surgical approach offers excellent exposure of the elbow joint, allows a solid repair of the triceps mechanism, and enables early mobilization after total elbow arthroplasty [185].

Functional milestones: Total elbow arthroplasty provides promising overall clinical outcomes for pain relief, restoration of function, and range of motion, with weighted mean Mayo Elbow Performance Scores of 85.3 points for rheumatoid arthritis and 84.1 points for trauma [273]. In a prospective cohort of patients with posttraumatic arthritis or deformities of the elbow, short-term functional outcomes were good according to mean postoperative measurements [23]. The mean Mayo elbow performance score significantly improved from 48 points preoperatively to 83 points at final follow-up [269]. In patients with surviving implants, 57% achieved good to excellent Mayo Elbow Performance Scores with predictable improvement in range of motion [99].

Other Considerations: The goal of treatment is to obtain a low level of pain with sufficient motion range to ensure good function, while preserving future surgical options and delaying elbow arthroplasty to the extent possible [1]. The Discovery elbow increased function and decreased pain with high survivorship at a mean of 4.1 years [13]. A satisfactory outcome after total elbow replacement can be obtained for the majority of patients with serious preoperative conditions of the elbow [71]. In the course of total elbow arthroplasty, satisfactory supportive range of motion was restored to patients' elbow joints [82]. When successful, total elbow arthroplasty provided adequate pain relief and good functional restoration [91]. 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 [92]. Ninety-four percent of patients engaged in moderate-demand activities after total elbow arthroplasty, and forty percent engaged in high-demand activities [162]. Total elbow arthroplasty is a durable and effective option in alleviating pain and restoring motion in the salvage elbow [277]. Since the threshold for arthroscopic ulnohumeral arthroplasty is now low and it is also performed in the young and active population, the elbow may be at risk for intraarticular fractures in maximal loading immediately after surgery and some caution for resuming sport activities should be prompted [259]. A 1-stage procedure for shoulder and elbow arthroplasty reduces hospitalization time and does not adversely affect the clinical outcome compared to a 2-stage procedure [66].

Key Evidence

• [L4] The goal of treatment is to obtain a low level of pain with sufficient motion range to ensure good function, while preserving future surgical options and delaying elbow arthroplasty to the extent possible. [1] (10.1016/j.otsr.2013.11.004)
• [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. [2] (10.1177/1758573216677200)
• [L5] The continued success of total elbow arthroplasty will depend on advances in surgical planning, technique, implant design, and materials. [3] (10.5435/jaaos-d-25-00473)
• [L3] In most cases, elbow function was maintained in the long-term without loosening of the implant. [5] (10.1302/0301-620x.99b6.bjj-2016-1033.r2)
• [L5] Total elbow arthroplasty designs have evolved, but long-term outcome data remain limited. [6] (10.1016/j.hcl.2011.01.003)
• [L3] Patients undergoing elective total elbow arthroplasty have slightly higher complication rates than those undergoing shoulder, hip, or knee arthroplasty. [7] (10.1016/j.jhsa.2016.07.007)
• [L5] Total elbow arthroplasty remains the most definitive functional procedure for patients with end-stage painful arthritis of the elbow. [8] (10.1097/01.bth.0000181293.38237.f0)
• [L4] Total elbow arthroplasty remains associated with substantial complication and reoperation rates. [9] (10.1016/j.jhsg.2026.100981)
• [L4] The review focuses on the evolution of the elbow arthroplasty, from a historic overview, up to the present and addresses issues that could improve the clinical outcome in today's practice. [10] (10.5312/wjo.v7.i1.44)
• [L4] Total elbow arthroplasty has become a reliable treatment option for elbows severely affected by rheumatoid arthritis, with recent reports showing decreased prevalence of complications, maintenance of excellent pain relief, and functional restoration. [11] (10.2106/00004623-199805000-00008)
• [Paper] Elbow arthroplasty is very successful in terms of pain relief, motion and function. [12] (10.2174/1874325001105010115)
• [L4] The Discovery elbow increased function and decreased pain with high survivorship at a mean of 4.1 years. [13] (10.1016/j.jse.2013.12.033)
• [L4] The review discusses various approaches to total elbow arthroplasty and their reported outcomes to assist surgeons in making an informed choice. [14] (10.1177/1758573216682479)
• [L5] Total elbow arthroplasty is an effective treatment for various conditions about the elbow, with the main goal being pain relief. [16] (10.1053/j.oto.2013.09.002)
• [L4] The complication and revision rates are comparable to other indications for elbow replacement surgery. [17] (10.1177/17585732211014832)
• [L4] The age at surgery is a risk factor for complications, and the indication for total elbow arthroplasty in patients under 60 should be carefully considered. [18] (10.1016/j.otsr.2013.10.012)
• [Paper] Currently, there is insufficient evidence to identify the best type of elbow implant, and the choice is determined by surgeons' preference, familiarity, and patients' particular circumstances. [19] (10.1016/j.hcl.2011.01.004)
• [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. [22] (10.1302/0301-620x.96b10.33815)
• [L4] Short-term functional outcomes after total elbow arthroplasty in this prospective cohort of patients with posttraumatic arthritis or deformities of the elbow were good according to mean postoperative measurements. [23] (10.1016/j.jhsa.2013.03.051)
• [L4] Surveillance efficacy is higher in primary linked total elbow arthroplasty than primary shoulder arthroplasty, supporting appropriate resource allocation for elbow arthroplasty surveillance. [24] (10.1177/17585732241301356)
• [L4] [26] (10.1016/j.jse.2026.04.042)
• [L4] [27] (10.1016/j.ocl.2013.03.009)
• [L5] Total elbow arthroplasty may be performed in younger patients for whom no other alternatives are available, although joint-preserving procedures for elbow arthritis are generally more successful than other surgical options for shoulder arthritis. [30] (10.3810/psm.2013.02.1998)
• [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. [32] (10.1016/j.jhsa.2012.12.037)
• [L5] Total elbow arthroplasty (TEA) indications have changed markedly in the past decade to address the sequelae of trauma rather than inflammatory conditions. [34] (10.1016/j.ocl.2018.02.009)
• [L2] The range of indications for total elbow arthroplasty is broadening; total elbow arthroplasty for acute trauma and osteoarthritis is becoming increasingly more common. [36] (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. [37] (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. [38] (10.1177/1758573221991511)
• [L4] This retrospective review supports a recommendation for total elbow arthroplasty when strict inclusion criteria are observed. [40] (10.2106/jbjs.d.02871)
• [L4] Total elbow arthroplasty carries a higher risk of infection when compared to other major joint replacements. [42] (10.1177/1758573218789341)
• [L4] Interposition arthroplasty can improve elbow motion and function but at the expense of elbow stability despite hinged external fixation. [43] (10.1016/j.jse.2007.11.008)
• [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. [44] (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. [45] (10.2106/00004623-198971040-00006)
• [L3] The worst outcomes were found in patients undergoing total elbow replacement for fracture sequelae, where there was a relative risk of revision of 6 compared to inflammatory arthropathy. [47] (10.3109/17453674.2013.784658)
• [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. [51] (10.1302/2058-5241.2.160064)
• [L3] The results of revision at a minimum of two years were inferior to those of primary capitellocondylar total elbow arthroplasty. [59] (10.2106/00004623-199610000-00012)
• [L4] [63] (10.1016/j.jse.2022.03.021)
• [L4] [64] (10.1016/j.jse.2011.03.005)
• [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. [65] (10.1016/j.jse.2021.09.005)
• [L3] A 1-stage procedure for shoulder and elbow arthroplasty reduces hospitalization time and does not adversely affect the clinical outcome compared to a 2-stage procedure. [66] (10.1016/j.jse.2007.03.033)
• [L4] [67] (10.2106/jbjs.03031pp)
• [L4] A satisfactory outcome after total elbow replacement can be obtained for the majority of patients with serious preoperative conditions of the elbow. [71] (10.1016/j.jse.2006.01.013)
• [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. [73] (10.1016/j.jhsa.2018.11.005)
• [L5] Total elbow arthroplasty is an effective treatment for end-stage arthritis of the elbow, with results in patients with rheumatoid arthritis appearing nearly as free of complications as those performed for other indications, though it should be considered a last step due to the lack of other options after replacement. [74] (10.1016/j.hcl.2010.10.003)
• [L4] Survival rates nonetheless remain low and complication rates remain high yet are comparable to those of other elbow arthroplasties. [75] (10.1016/j.jse.2021.08.028)
• [L4] [79] (10.2106/00004623-198870010-00031)
• [L4] Concomitant total wrist and elbow arthroplasty is a viable option for selected patients with ipsilateral degenerative changes, offering benefits such as reduced recovery time, lower costs, and decreased morbidity compared to two-stage procedures. [80] (10.1055/s-0035-1569483)
• [L4] [81] (10.1016/j.jse.2005.09.002)
• [L4] In the course of total elbow arthroplasty, satisfactory supportive range of motion was restored to patients' elbow joints. [82] (10.1136/annrheumdis-2014-eular.2916)
• [L3] [83] (10.2106/00004623-200010000-00003)
• [L3] Within the follow-up limitations of this report, the 2 types of elbow prosthesis seem equally durable. [84] (10.1067/mse.2000.109408)
• [L4] Convertible prostheses may provide a solution when elbow stability can be determined intraoperatively, with recent long-term results described as promising. [85] (10.2106/jbjs.rvw.18.00127)
• [L3] Total elbow arthroplasty for distal humerus fractures provided similar clinical and functional outcomes when performed as a primary procedure or after failed internal fixation. [86] (10.1097/bot.0000000000001631)
• [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. [90] (10.1016/j.jse.2015.11.048)
• [L4] When successful, total elbow arthroplasty provided adequate pain relief and good functional restoration. [91] (10.1016/j.jse.2026.07.008)
• [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. [92] (10.1016/j.jhsg.2023.05.006)
• [L3] Obesity adversely influences the performance of elbow replacement after primary total elbow arthroplasty. [95] (10.2106/jbjs.m.00364)
• [L1] [96] (10.1007/s00402-017-2687-x)
• [L3] [97] (10.1177/17585732211043524)
• [L4] In patients with surviving implants, 57% achieved good to excellent Mayo Elbow Performance Scores with predictable improvement in range of motion. [99] (10.5435/jaaos-d-18-00055)
• [Abstract] Additional surgery for non-infectious reasons was performed in 14 (44%) of elbows free of infection. [101] (10.1016/j.jse.2022.01.066)
• [L1] Shoulder and elbow PJI may be on a temporal decline. [103] (10.1016/j.jinf.2020.01.008)
• [L3] [115] (10.1111/j.1758-5740.2009.00011.x)
• [L3] [119] (10.1016/j.jsea.2026.100027)
• [L4] [120] (10.1016/j.jse.2008.11.014)
• [Case_report] [121] (10.2106/00004623-199907000-00015)
• [L5] Shoulder abduction results in a varus moment at the elbow. [126] (10.1016/j.jhsa.2018.04.022)
• [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. [131] (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. [132] (10.1016/j.xrrt.2025.08.016)
• [L4] Total elbow arthroplasty can be a valid alternative in the surgeon's treatment armamentarium for complex distal humerus fractures in elderly patients who have moderate functional demands. [134] (10.1016/j.otsr.2012.10.010)
• [L3] Total elbow arthroplasty is a recognized and preferable option compared with synovectomy or interpositional arthroplasty for the management of most patients who have rheumatoid arthritis. [136] (10.2106/00004623-199809000-00012)
• [L4] Our short-term results demonstrate that unlinked, noncongruous elbow arthroplasty can be a successful alternative in the management of acute distal humeral fractures, when internal fixation is not a viable option. [151] (10.1016/j.jse.2007.06.011)
• [L4] [154] (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. [157] (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. [162] (10.1016/j.jse.2013.01.023)
• [L5] Total elbow arthroplasty remains an alternative to osteosynthesis with very satisfactory immediate results restoring a painless, stable, and functional elbow. [169] (10.1016/j.otsr.2014.06.008)
• [L4] [183] (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. [185] (10.1177/1758573214559319)
• [L1] [201] (10.1186/s12891-019-2848-x)
• [L4] [203] (10.2106/00004623-198163070-00002)
• [L4] Total elbow arthroplasty performed in United States university medical centers is associated with low in patient complication rates that include DVT 0.8%, re-operation 0.5%, and infection 0.4%. 4.4% of patients were readmitted to the hospital within 30 days of the index procedure. [206] (10.4081/or.2016.6113)
• [L4] [208] (10.1097/bth.0000000000000079)
• [L1] Osteocapsular debridement is an effective surgical treatment option for patients with symptomatic primary elbow osteoarthritis who have failed conservative management. [212] (10.1016/j.jse.2020.01.061)
• [L2] Osteocapsular debridement is an effective surgical treatment option for patients with symptomatic primary elbow osteoarthritis who have failed conservative management. [213] (10.1016/j.jse.2020.01.060)
• [L4] [216] (10.5435/jaaos-21-07-427)
• [L5] [217] (10.1016/j.jse.2010.12.004)
• [L2] [220] (10.1016/j.jhsa.2022.07.020)
• [L4] A 3% incidence of significant ulnar nerve complications after total elbow arthroplasty compares favorably with systematic reviews. [222] (10.1016/j.jhsa.2015.06.107)
• [L4] [223] (10.1016/j.jseint.2024.08.004)
• [L4] Total elbow arthroplasty for fracture in elderly patients provides pain relief, functional range of motion, and good patient-reported outcome scores. [225] (10.1016/j.jhsa.2020.10.034)
• [L5] [226] (10.1016/j.jhsa.2024.09.006)
• [L4] [230] (10.1097/blo.0b013e31802e1968)
• [L4] There is concern about early radiologic loosening of the radial component, though this has not resulted in clinical symptoms or implant failure yet. [232] (10.1016/j.jse.2017.06.037)
• [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. [233] (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. [234] (10.1016/j.jse.2024.03.032)
• [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. [238] (10.1016/j.jse.2007.02.051)
• [L4] All unnotched group aseptic loosening cases occurred at the bone-cement interface within 2 years after total elbow arthroplasty. [246] (10.1177/17585732221150799)
• [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. [247] (10.1016/j.jse.2021.03.063)
• [L1] The overall significant complication rate for modern total elbow arthroplasty is 24.3% ± 5.8%. [248] (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. [249] (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. [251] (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. [252] (10.1016/j.jse.2014.02.001)
• [Paper] Therefore, pre-operative templating using plain elbow radiographs does not add benefits in pre-operative decision making. [253] (10.1007/s00402-016-2444-6)
• [L4] Inferior implant survivorship was demonstrated in TEA of the dominant vs. nondominant elbow, which confers a 4.5-fold relative risk of revision. [254] (10.1016/j.jse.2020.12.007)
• [L3] If a radial head prosthesis is used, prosthesis oversizing should be avoided as it may contribute to worse outcome with other radiographic abnormalities. [255] (10.1007/s00264-014-2478-8)
• [L4] However, an unusually high rate of complications and revisions was observed, mainly at the humeral component. [256] (10.1016/j.jse.2021.02.009)
• [L5] Periprosthetic joint infection after total elbow arthroplasty is relatively common and difficult to eradicate, with prevention being key. [257] (10.1302/0301-620x.106b11.bjj-2024-0549.r1)
• [L4] However, since the threshold for this surgical procedure is now low and it is also performed in the young and active population, the elbow may be at risk for intraarticular fractures in maximal loading immediately after surgery and some caution for resuming sport activities should be prompted. [259] (10.1155/2011/798084)
• [Paper] Further follow-up is required to investigate the radiological changes observed in some of our patients. [261] (10.1007/s00402-015-2191-0)
• [L4] Increased incidence of radiolucent lines around the ulnar stem and bushing wear with longer follow-up is of concern and represents the failure mode for this total elbow arthroplasty implant. [262] (10.1016/j.otsr.2013.07.002)
• [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. [263] (10.1016/j.xrrt.2025.06.013)
• [L4] The mean Mayo elbow performance score significantly improved from 48 points preoperatively to 83 points at final follow-up. [269] (10.1007/s10165-011-0509-5)
• [L4] However, many patients have radiolucencies, and the discrepancy between clinical signs and radiological results warrants structural follow-up. [270] (10.1186/s12891-019-2781-z)
• [L2] Total elbow arthroplasty provides promising overall clinical outcomes for pain relief, restoration of function, and range of motion, with weighted mean Mayo Elbow Performance Scores of 85.3 points for rheumatoid arthritis and 84.1 points for trauma. [273] (10.4055/cios.2019.11.4.369)
• [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. [274] (10.1016/j.jse.2024.11.034)
• [Abstract] Total elbow arthroplasty is a durable and effective option in alleviating pain and restoring motion in the salvage elbow. [277] (10.1016/j.jse.2007.02.071)
• [L4] Two-stage revision was the most effective treatment for elbow PJI, showing the lowest recurrence rate for infection. [278] (10.1016/j.jse.2019.10.002)
• [L4] Because of the difficulty in achieving solid fusion and an increased complication rate, the authors cannot recommend elbow arthrodesis as a salvage procedure for failed TEA with deep infection. [279] (10.1016/j.jse.2013.11.007)

See Also

• Elbow Osteoarthritis
• Cubital Tunnel Syndrome
• Radial head arthroplasty
• Distal Humerus Fracture
• Neuropathies

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