Elbow Arthroplasty

Total elbow replacement — indications, implants, and recovery.

Overview

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 [31]. The range of indications is broadening, with procedures for acute trauma and osteoarthritis becoming increasingly common [14]. Continued success depends on advances in surgical planning, technique, implant design, and materials [2], while ongoing improvements in exposure, design, and complication management aim to make the procedure as reliable as hip or knee arthroplasty [1].

Patients undergoing elective total elbow arthroplasty experience slightly higher complication rates than those undergoing shoulder, hip, or knee arthroplasty [4]. Complication and revision rates for joint replacement in elbow tumours are comparable to other indications [7]. While the largest systematic review of complications has been conducted [8], survival rates for the Latitude primary total elbow arthroplasty remain low with high complication rates, yet these figures are comparable to other elbow arthroplasties [21]. Functional improvement is achievable when proper indications are satisfied, including patient understanding of risks and ability to comply with postoperative rehabilitation [18].

Alternative strategies include lateral resurfacing elbow arthroplasty, a satisfactory option with lower complication rates that does not require activity restrictions to the same extent as total elbow arthroplasty [15]. Convertible total elbow arthroplasty provides good to excellent outcomes and substantial range of motion improvements with careful patient selection [16]. Various approaches and their reported outcomes are discussed to assist surgeons in making an informed choice [6].

Anatomy & Pathophysiology

Osseous Architecture

The elbow functions as a trocho-ginglymoid joint with medial and lateral articulations providing bony stability [47]. The ulnohumeral joint, formed by the trochlea and the greater sigmoid notch of the ulna, exhibits high congruency with nearly 180° of articular contact, excluding the cartilage-free bare area of the greater sigmoid notch [47]. The coronoid process features medial and lateral facets that buttress the trochlea anteriorly, while the sublime tubercle, located distal and medial to the coronoid, anchors the anterior bundle of the medial ulnar collateral ligament (MUCL) [47]. The distal humeral articular surface is angled 30° from the longitudinal axis, with the anterior humeral line passing through the center of the axis of rotation [47]. This axis is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side more distal, accounting for the shift from a valgus carrying angle to a more varus position during flexion [47]. The distal humerus comprises medial and lateral columns diverging from the shaft at 45° and 20°, respectively [52][53]. The radiocapitellar joint involves the capitellum and the concave elliptical radial head, which is covered in cartilage along the joint and approximately 270° of its margin [47]. The radial head articulates with the lesser sigmoid notch of the ulna, held in close approximation by the annular ligament [47]. Posteriorly, the olecranon provides a broad attachment for the triceps, while anteriorly, the brachialis inserts on the coronoid and ulnar tuberosity [53]. The ulna bends medially approximately 8° at 8 cm from the olecranon tip and possesses a slight anterior bow, with the coronoid articulation angled 30° from the ulnar long axis in the sagittal plane [47]. A high correlation exists between the size of the radius and capitellum within an individual, aiding surgical planning when one side is destroyed [47].

Ligamentous Stability

Elbow stability relies on primary and secondary stabilizers [24]. The three primary stabilizers are the ulnohumeral articulation, the medial ulnar collateral ligament (MUCL), and the lateral ulnar collateral ligament (LUCL) complex [24]. The anterior bundle of the MUCL is the primary restraint to valgus stress within the functional range of motion, originating on the posterior medial epicondyle and inserting on the sublime tubercle [51]. The posterior bundle of the MUCL serves as the primary restraint to valgus stress in maximal flexion [51]. Stability in full extension is provided by the MCL, joint capsule, and ulnohumeral articulation [51]. In full extension, 60% of axial load is transmitted through the radiocapitellar joint [51]. Secondary stabilizers include the radiocapitellar articulation, common flexor and extensor tendons, and the joint capsule [24]. The lateral epicondyle serves as the origin for the lateral extensor musculature, with the LUCL complex originating just distal to it at the geometric center of the radiocapitellar articulation [47]. The most critical portion of the MUCL is the anterior segment, attaching to a small process on the medial surface of the coronoid [53]. The normal valgus carrying angle measures 5 to 10 degrees in men and 10 to 15 degrees in women [51].

Kinematics and Functional Arc

The normal elbow range of motion spans 0° to 140° for flexion-extension and 75° to 85° for pronation-supination [24]. A functional arc requires 100° in each plane for flexion-extension and forearm rotation [24]. Normal flexion-extension ranges from 0 to 150 degrees, with forearm rotation at 80 to 85 degrees in each direction [52]. The functional range of motion is defined as 30 to 130 degrees for flexion-extension and 50 degrees for pronosupination [52]. With the elbow at 90° of flexion, the medial condyle, lateral condyle, and olecranon form a palpable triangle [53]. Shoulder abduction induces a varus moment at the elbow [59]. Recent device design changes are driven by biomechanical and clinical outcome research to better reproduce elbow kinematics [25]. Insertion of a correctly sized metallic radial head replacement recreates near-normal forearm biomechanics without altering interosseous membrane loading [65]. However, overstuffing the radial head prosthesis alters joint kinematics and may cause pain and degenerative changes [80]. Kinematics deviate increasingly from the native joint with 2 mm to 4 mm lengthening of the radius [48]. Biomechanically, monopolar radial head prostheses offer superior stability enhancement compared to bipolar designs [61]. Radiocapitellar prosthetic arthroplasty largely preserves elbow kinematics and stability [43]. Cementing a nonanatomic hinge that does not rely on native soft tissue support can create a troubling biomechanical environment [64]. The valgus angulation of available elbow designs is discordant with mean native valgus angulation, and implant laxity does not cover population variability [83]. The plane through the ridge of the greater sigmoid notch provides a more reliable landmark for estimating the flexion-extension axis than the posterior surface [95]. TEA patients differ from healthy controls in task execution of ADLs regarding functional flexion-extension angles, joint load, and peak power for straining tasks [92].

Pathophysiology and Imaging

Osteoarthritis of the elbow is characterized by osteophyte formation, capsular contracture, and loose bodies, often with relative preservation of the joint space [38]. Periarticular hypertrophic osteophytes act as mechanical blocks at the end ranges of flexion and extension [38]. Osteoarthritis typically involves the radiocapitellar joint articular cartilage preferentially, with relative preservation of the ulnohumeral surfaces [38]. Patients with primary osteoarthritis present with loss of terminal extension and flexion, painful catching, clicking, or locking [38]. Pain is typically noted at end ranges of motion rather than through the midrange, and night pain is atypical; its presence suggests an inflammatory cause [38]. Ulnar neuropathy is present in up to 50% of patients with primary osteoarthritis [38]. Radiographs typically show osteophytes at the coronoid process, coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa [38]. Joint spaces at the ulnohumeral joint are usually preserved, while those at the radiocapitellar joint are mildly narrowed [38]. Radiographs typically underestimate the number of loose bodies present [38]. Plain radiographs remain the hallmark screening test for elbow pathology [24]. Ultrasonographic imaging includes techniques and normal anatomical appearances [26]. MRI evaluation covers ligament complexes, instability patterns, and soft-tissue lesions from dislocation [26]. Common findings in asymptomatic professional baseball pitchers include collateral ligament thickening and ulnar nerve abnormalities [26]. MRI findings of structural changes in overhead throwers correlate with clinical presentation [26]. UCL injury patterns and acute elbow dislocation mechanisms are illustrated with MRI [26]. Normal and variant anatomy, osteochondral lesions, and osteochondritis dissecans of the capitellum are identifiable on MRI [26]. In vitro simulation of active cyclic elbow motion at varying shoulder abduction angles characterizes in vivo TEA performance [54]. Elbow joint loads during simulated ADLs have been analyzed to formulate post-TEA recommendations [44]. The most common mode of failure requiring revision is aseptic loosening, a consequence of inherent biomechanical challenges [68]. Improvement in range of motion should not be expected after revision elbow arthroplasty using the Latitude total elbow arthroplasty [69]. Variability in pathoanatomic conditions requires customized treatment aimed at stabilizer reconstruction if the ulnohumeral joint is preserved, or joint replacement for severe articular degeneration [94]. Evaluation requires an intimate understanding of anatomy, biomechanics, and diagnostic tests [24]. The physical exam is directed by history and pain location in the anterior, posterior, medial, or lateral aspects [24].

Classification

Primary Arthroplasty Management: Advances in exposure, implant design, and complication management address primary elbow arthroplasty problems and solutions [1]. The range of indications for total elbow arthroplasty is broadening, with use for acute trauma and osteoarthritis becoming increasingly common [14]. Complication and revision rates for joint replacement surgery for elbow tumours are comparable to other indications for elbow replacement surgery [7].

Kudo Classification: Elbow function is maintained in the long-term without implant loosening in most cases of Kudo type-5 total elbow arthroplasty for patients with rheumatoid arthritis [3].

Discovery System Surveillance: The Discovery elbow replacement demonstrates early clinical results similar to other semi-constrained total elbow replacements [9]. Continued radiological surveillance is warranted for humeral lucency in the Discovery elbow replacement system [9].

Surface-Replacement Prostheses (Type-1 and Type-2): Type-1 and Type-2 prostheses are associated with a high rate of subsidence or loosening of the humeral component in total elbow arthroplasty with a non-constrained surface-replacement prosthesis for rheumatoid arthritis [102]. Satisfactory clinical results were maintained in elbows followed for ten years or more despite high rates of subsidence or loosening of the humeral component with Type-1 and Type-2 prostheses [102].

Other Considerations: A staged protocol utilizing arthroscopic assessment refines the approach to the painful total elbow arthroplasty by directly influencing definitive surgical management [5]. The largest systematic review of total elbow arthroplasty complications has been conducted [8]. Short-term functional outcomes after total elbow arthroplasty in patients with posttraumatic arthritis or deformities of the elbow were good according to mean postoperative measurements [10]. Surveillance efficacy is higher in primary linked total elbow arthroplasty than in primary shoulder arthroplasty [11]. Core domains for the clinical outcomes of elbow replacement have been defined by consensus from patients, carers, and healthcare professionals [17]. Total elbow arthroplasty carries a higher risk of infection when compared to other major joint replacements [40]. There is a 3% incidence of significant ulnar nerve complications after total elbow arthroplasty [41]. The incidence of neurologic complications associated with the surgical treatment of complex elbow fractures requiring implantation of a radial head prosthesis may be underestimated in the literature [19]. There is a large variety of pathology and procedures involving the use of various types of allografts in orthopedic reconstructive surgery of the elbow and forearm [78].

Clinical Presentation

A thorough history and physical examination are invaluable for understanding the disease process and its impact on the patient [107]. Clinicians must determine the symptom trajectory, noting if pain is improving, worsening, or remaining constant [108]. Understanding whether pain occurs throughout the arc of motion or only at terminal limits is of paramount importance [107]. Treatment 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 range from arthroscopic debridement for pain at motion extremes to total elbow arthroplasty for pain throughout the arc of motion [13].

Acute Injury vs. Chronic Arthropathy

In trauma situations, the likelihood of significant joint pathology with normal elbow motion is so small as not to require radiographic analysis [106]. However, loss of motion, especially extension, particularly if the history suggests trauma, warrants a radiographic examination [106]. Loss of full extension is the first motion altered by most elbow pathology and the last to be regained [106]. Loss of passive extension is a sensitive but nonspecific sign of an intra-articular process [106]. Rupture of the triceps tendon or neurologic conditions should be suspected if there is loss of active extension [106]. Any significant difference between active and passive ranges of motion suggests pain or motor dysfunction as the cause [106].

Chronic Arthropathy: Osteoarthritis and Rheumatoid Arthritis

Symptomatic primary osteoarthritis affects 2% of the population, with an average presentation age of 50 years (range, 20 to 70 years) [38]. Men are affected more often than women with a 4:1 ratio, and hand dominance and strenuous manual labor are associated risk factors [38]. Secondary causes include trauma, osteochondritis dissecans, and synovial osteochondromatosis [38]. Patients typically present with loss of terminal extension and flexion, painful catching, clicking, or locking [38]. Pain is usually felt at the end ranges of flexion and extension rather than throughout the arc, and night pain is atypical; if present, an inflammatory cause should be considered [38]. Ulnar neuropathy is present in up to 50% of patients with elbow osteoarthritis [38].

In rheumatoid arthritis, when both the shoulder and elbow are involved, the joint causing the most pain and disability should be operated on first [72]. Primary diagnosis of rheumatoid arthritis significantly contributes to re-revision of total elbow arthroplasty [75]. In most cases of Kudo type-5 total elbow arthroplasty for rheumatoid arthritis, elbow function is maintained long-term without implant loosening [3]. Patients undergoing elective total elbow arthroplasty have slightly higher complication rates than those undergoing shoulder, hip, or knee arthroplasty [4].

Imaging and Diagnostic Workup

Plain radiographs should be obtained during the initial workup to evaluate the articular surface and bony anatomy [107]. For elbow osteoarthritis, radiographs typically show osteophyte formation at the coronoid process (anterior and medial), coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa [38]. Joint spaces at the ulnohumeral joint are usually preserved, while those at the radiocapitellar joint are mildly narrowed [38]. Loose bodies may be evident but are often underestimated on radiographs [38]. CT scans with 3D reconstructions may be useful for evaluating the extent and location of disease and for surgical planning [107]. CT is also useful for detailed assessment of osteophytes and loose bodies in elbow osteoarthritis [38]. MRI may be useful to evaluate the status of soft tissues, including the medial and lateral collateral ligamentous complexes [107]. Electromyography and nerve conduction studies may be useful to evaluate the degree of nerve compression and contribution to elbow pain or dysfunction [107].

Physical Examination: Inspection, Palpation, and Range of Motion

The fundamental elements of the elbow examination include inspection, palpation, range of motion, strength, stability, and special tests [108]. The location, quality, context, duration, and severity of elbow pain are all important to understanding pathology [108]. Associated conditions such as cubital tunnel syndrome must be considered and evaluated [107]. Flexion contractures of less than 45° may have little practical significance, although patients may be concerned about cosmetic appearance [106]. To perform 90% of required daily activity, 50° of pronation and supination are required [106]. For most individuals, pronation is the most important function on the dominant side for eating and writing [106]. Loss of supination of the nondominant side may significantly hinder personal hygiene needs, accepting objects, and opening door handles [106]. A normal change in carrying angle from valgus to varus is observed as the patient flexes the elbow and supinates the forearm [106].

Special Tests and Stability

The simple extension test has a sensitivity of 97% and a negative predictive value of 98% [106]. The specificity of the simple extension test is 69%, with a positive predictive value of 63% [106]. Reproduction of radiocapitellar pain with combined flexion or extension under a load, as in the radiocapitellar load test, signals a problem with the joint [106]. In patients with surviving implants after hemiarthroplasty for posttraumatic arthritis, 57% achieved good to excellent Mayo Elbow Performance Scores with predictable improvement in range of motion [23]. After 15 years, elbows treated with radial head arthroplasty presented signs of arthritis in the majority of patients [67].

Surgical Decision-Making and Complications

Treatment of elbow arthritis must be individualized based on etiology, severity, patient age, and functional demands [13]. Surgical indications for elbow osteoarthritis include failure to respond to nonsurgical interventions, loss of motion interfering with activities of daily living, and painful locking or catching [38]. Total elbow arthroplasty is rarely indicated for elbow osteoarthritis and is not indicated for patients younger than 65 years or physically active patients due to concerns about implant longevity [38]. Joint-sparing procedures such as débridement, excision of osteophytes, capsular release, and removal of loose bodies are preferred for elbow osteoarthritis [38]. Total elbow arthroplasty can be a successful treatment for end-stage elbow osteoarthritis associated with Paget's disease if preoperative planning accounts for distorted anatomy and potential bone defects [73].

Various approaches to total elbow arthroplasty have been reviewed to assist surgeons in making informed choices regarding their reported outcomes [6]. A staged protocol utilizing arthroscopic assessment refines the approach to the painful total elbow arthroplasty by directly influencing definitive surgical management [5]. The largest systematic review of total elbow arthroplasty complications has been conducted [8]. Arthrofibrosis is a well-described complication after total knee arthroplasty and has been described after total elbow arthroplasty [71]. The incidence of neurologic complications associated with surgical treatment of complex elbow fractures requiring radial head prosthesis implantation may be underestimated in the literature [19]. Primary elbow arthroplasty problems and solutions are addressed through advances in exposure, implant design, and complication management [1].

Specific Procedural Considerations

Outerbridge-Kashiwagi arthroplasty is the classic open procedure for elbow osteoarthritis where the olecranon fossa is trephinated and osteophytes are removed [38]. Limitations include incomplete anterior release and incomplete osteophyte removal anteriorly [38]. Either a medial or lateral column approach can be used for open débridement, loose body removal, osteophyte resection, and capsulectomy [38]. Contraindications for arthroscopic procedures in elbow osteoarthritis include severe contracture and periarticular heterotopic ossification [38]. Relative contraindications include prior ulnar nerve transposition and prior extensive open procedures [38]. Osteocapsular arthroplasty refers to the arthroscopic technique involving capsular release, loose body removal, and excision of osteophytes [38]. Ulnar nerve transposition and release of the posterior bundle of the medial collateral ligament should be considered for patients with less than 90° to 100° of elbow flexion [38].

Deep infections in the elbow are more common than other joints treated arthroscopically (0.8% to 2.2%) [38]. Infection related to intraoperative corticosteroid injections can manifest in elbow osteoarthritis procedures [38]. Stiffness (heterotopic ossification), hematoma formation, and synovial ganglion formation are complications of elbow osteoarthritis procedures [38]. Transient nerve palsies complicate 1% to 3% of elbow osteoarthritis procedures, with radial and ulnar nerves most common [38]. During arthroscopic surgery, joint distention moves the capsule away from bone, but the distance between neurovascular structures and the capsule remains unchanged [38]. Neurovascular structures at risk during portal placement, débridement, and capsular release include the median nerve (anteromedial), the ulnar nerve (posteromedial), and the radial nerve (adjacent to the anterolateral capsule) [38]. The brachialis muscle protects the median nerve and brachial artery during capsular procedures [38].

Resection of olecranon osteophytes needs to be extended along the medial and lateral aspects of the olecranon to allow maximal extension and prevent impingement along the medial and lateral posterior columns [38]. The olecranon fossa is an oval structure that is wider in the medial to lateral dimension [38]. The olecranon osteophytosis extends medially and laterally and not just at the tip [38]. Coronoid osteophytosis extends medially and not just at the tip [38]. Resection of coronoid osteophytes should be extended medially if necessary to maximize the restoration of flexion range of motion [38]. Core domains for the clinical outcomes of elbow replacement have been defined by consensus from patients, carers, and healthcare professionals [17]. 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]. Short-term functional outcomes after total elbow arthroplasty in patients with posttraumatic arthritis or deformities of the elbow were good according to mean postoperative measurements [10].

Investigations

Plain radiography: Plain radiographs remain the hallmark and best screening test for elbow evaluation [24]. Standard imaging includes AP, lateral, and oblique views [28], which are necessary to document congruent reduction after dislocation [60] and may reveal posteromedial olecranon osteophytes and/or loose bodies [57]. Oblique views are particularly useful for identifying periarticular fractures [60]. Serial radiography is indicated as follow-up when heterotopic ossification is present [28]. The normal elbow demonstrates a range of motion from 0° to 140° from extension to flexion and 75° to 85° in pronation and supination respectively, with a functional arc of 100° in each plane [24].

CT: CT is beneficial if any joint incongruity or abnormal bony anatomy is present [28] and is helpful when assessing for malunion architecture, the location and pattern of osteophytes, and/or loose bodies [28]. It is particularly useful for identifying mineralized intra-articular loose bodies or delineating the anatomy of a complex intra-articular fracture [56]. CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes posteromedial olecranon osteophytes and loose bodies [57]. Three-dimensional CT is used to check for heterotopic ossification [28]. CT is not necessary when elbow stiffness is entirely soft-tissue related [28]. In the setting of elbow dislocation, CT is useful to identify associated osseous injury [60] and should be considered with an incongruous reduction to identify potential incarcerated osteocartilaginous fragments [60].

MRI: MRI is the imaging modality best suited for evaluating soft-tissue structures in the elbow, including ligaments, tendons, cartilage, and nerves [56]. It can be used to evaluate ligaments and tendons but is rarely indicated for elbow stiffness [28]. Magnetic resonance arthrography (MRA) is particularly beneficial in the evaluation of osteochondral lesions, loose bodies, and ulnar collateral ligament (UCL) injury in a throwing athlete [56]. 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) [56]. Coronal MRI studies should be obtained along a line connecting the medial and lateral epicondyles [56], while sagittal MRI studies should be perpendicular to the coronal studies [56]. MRI may be most helpful in evaluating associated injuries, including partial or complete tears of the MCL in valgus extension overload syndrome [57].

MRI Technical Parameters and Interpretation: 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 [56]. However, 3-Tesla imaging can show mild signal alterations of tendons, ligaments, and nerves of the elbow that may not be symptomatic [56]. Ligaments and tendons appear anechoic (black) on all MRI sequences [56]; with tissue remodeling or degeneration, the signal increases on all MRI sequences [56]. Tears are diagnosed by identifying signal in the tissue that brightens to the level of simple fluid, representing focal discontinuity of tendon or ligament fibers [56]. Tears can be partial or full thickness [56]. Partial tears are described by identifying whether the involved pathology occurs at the articular side, intrasubstance, or involved superficial fibers [56]. Both partial-thickness and full-thickness tears should identify whether failure occurs proximally, mid-substance, or distally [56].

Ultrasonography: Radiography, CT, ultrasonography, and MRI each have a role in elbow imaging [56]. Ultrasonographic soft-tissue evaluation in the elbow is most useful in evaluating the distal biceps and the common flexor and extensor tendons [56]. Ultrasonography allows dynamic imaging, which may be useful in evaluating for ulnar nerve subluxation or a snapping triceps [56].

Other Considerations: The three primary stabilizers of the elbow are the ulnohumeral articulation, the medial ulnar collateral ligament (MUCL), and the lateral ulnar collateral ligament (LUCL) complex [24]. Secondary stabilizers include the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [24]. Active and passive flexion, extension, supination, and pronation should be evaluated using a goniometer for accurate measurement [28]. If the elbow has less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament (MCL) is contracted and must be released to restore flexion [28]. Mid arc ROM pain is more common with intrinsic disease and may not improve with contracture release alone [28]. The ulnar nerve is of utmost importance in elbow examination due to its anatomic proximity [28]. Electromyography/nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists [28]. An assessment for ulnar nerve subluxation should be performed [28], and subluxation of the ulnar nerve is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [28]. Verification of ulnar nerve transposition is required if there is a history of prior surgical procedures [28]. The primary bony landmarks for elbow radiographs include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [28]. 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 [114].

Post-Arthroplasty Imaging: Heterotopic ossification after total elbow arthroplasty is seen more commonly than previously reported [117]. Poor ulnar cementation may predict radiological loosening and eventual need for revision in total elbow arthroplasty [121], though radiological loosening in total elbow arthroplasty does not correlate with the patient's clinical outcomes [121]. Periprosthetic tissues of total elbow patients who have undergone revision for loosening and osteolysis contain polyethylene, cement, and metal debris [130]. 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 [113]. A 69-year clinical and radiologic follow-up of a McKee radial head prosthesis has been reported [116]. The overall interobserver reliability of radiographic assessment following press-fit bipolar radial head arthroplasty was poor among experienced elbow surgeons [124]. Most literature dealing with elbow arthroplasty consists of retrospective observational studies with small sample sizes and short follow-up [42].

Treatment

Non-Operative

Nonsurgical management may provide relief in early stages of elbow arthritis [13]. Treatment of elbow arthritis must be individualized based on etiology, severity, patient age, and functional demands [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].

Operative

Indications: The primary indications for total elbow arthroplasty are pain and/or instability [36]. An unreconstructible distal humeral fracture in an elderly patient is an increasingly common indication for total elbow arthroplasty [36]. Rheumatoid arthritis with radiographic evidence of joint destruction that is too far advanced to benefit from radial head excision and synovectomy is generally considered an indication [36]. Elderly patients with end-stage posttraumatic sequelae are acceptable candidates for total elbow replacement [36]. Bony or fibrous ankylosis with the elbow in a poorly functioning position is another indication for elbow arthroplasty [36]. Functional improvement is possible by means of total elbow replacement for complete ankylosis of the elbow when proper indications are satisfied, including patient understanding of risks and ability to comply with postoperative rehabilitation [18]. The range of indications for total elbow arthroplasty is broadening, with use for acute trauma and osteoarthritis becoming increasingly common [14]. 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 [39]. 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 [36]. The best candidate for total elbow replacement is a patient with severely painful and disabling rheumatoid arthritis with altered articular architecture [36]. Obese patients being considered for elbow replacement surgery should be counseled accordingly [34].

Surgical Approach / Technique: The "global" approach allows circumferential exposure of the elbow, reaching the collateral ligaments, ligaments, coronoid process, and anterior joint capsule [27]. The Van Gorder approach is the largest study evaluating the surgical approach to the elbow for primary TEA with an average follow-up of 32 months [58]. 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 [62]. A medial single-window approach to the elbow ensures sufficient visualization for total elbow arthroplasty while minimizing postoperative complications and allowing early safe mobilization [63]. A staged protocol utilizing arthroscopic assessment has refined the approach to the painful total elbow arthroplasty because it directly influences the definitive surgical management of the patient [5]. Various approaches to total elbow arthroplasty and their reported outcomes are discussed to assist surgeons in making an informed choice [6]. When proximal dissection is warranted to remove a well-fixed humeral stem, formally identifying and protecting the radial nerve is recommended over simple palpation [104].

Implant Selection: Initial "fixed-hinge" designs were plagued with failure due to fully constrained hinges allowing less than 1 degree of varus–valgus laxity, which transferred profound forces through the bone–implant interface [35]. Unlinked implants rely on intact capsuloligamentous restraints for stability and function and aim to lower aseptic loosening by dissipating forces through the ligaments and capsule [35]. 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 [35]. The semiconstrained TEA was developed in the 1970s to provide inherent stability and a "sloppy hinge" allowing 7 degrees of varus–valgus and 7 degrees of axial rotation to dissipate forces [35]. 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 [36]. Lateral resurfacing elbow arthroplasty is a satisfactory alternative to total elbow arthroplasty with lower rates of complications [15]. Lateral resurfacing elbow arthroplasty does not require activities to be restricted to the same extent as total elbow arthroplasty [15]. With careful patient selection, convertible total elbow arthroplasty provides patients with good to excellent outcomes and substantial improvements in the range of movements [16]. 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 [37]. 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 [25]. In the non-weight-bearing elbow, total joint replacement or use of acrylic cement may not be necessary [103].

Alignment / Balancing Strategy: In most cases, elbow function was maintained in the long-term without loosening of the implant for Kudo type-5 total elbow arthroplasty in patients with rheumatoid arthritis [3]. A 2005 systematic review including 86 articles showed 78% good–excellent results for TEA, with rates of 82% for semiconstrained implants, 78% for unlinked, and 73% for fixed hinge [35]. A recent review showed decreased aseptic loosening of linked compared with unlinked prostheses (p < 0.005) [35]. A recent review found revision was lower for linked (13.8%) versus unlinked (16.3%) prostheses (p = 0.015) [35]. A 2011 study suggested an overall 24.3% complication rate, which was slightly lower for linked (25.9%) versus unlinked (27.2%) prostheses [35]. A 2011 study found clinical instability was lower in linked (1.4%) versus unlinked (4.9%) implants [35]. Sanchez-Sotelo and colleagues reported an 11% revision rate with revision-free implant survivorship of 92% at 10 years, 83% at 15 years, and 68% at 20 years for TEAs done for rheumatoid arthritis [35]. Higher demand, male gender, trauma-related indications, and young age have consistently been linked to poorer outcomes and higher risk of revision following TEA [35]. 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 [93]. Linking the Latitude total elbow prosthesis results in increased valgus stability [97].

Pain Management: Patients with elbow arthroplasty had moderate pain, but limited grip strength and ROM, 1 year to 5 years after surgery [112]. Total elbow arthroplasty for fracture in elderly patients provides pain relief, functional range of motion, and good patient-reported outcome scores [111].

Adjuncts: Complication and revision rates for joint replacement surgery for elbow tumours are comparable to other indications for elbow replacement surgery [7].

Revision: Revision total elbow arthroplasty remains a difficult salvage situation and patients should be counseled as to the end-stage nature of their disorders before intervention so that expectations are properly set [104]. Revision is most commonly performed for aseptic loosening, deep infection, and periprosthetic fracture in decreasing order [35]. For deep infection after elbow implant arthroplasty, removal of the implant has been recommended, although more recent recommendations allow for retention of well-fixed components [104]. For superficial infection, debridement with salvage of the implant, resection arthroplasty, or elbow arthrodesis is recommended [104]. In patients with gross loosening of the implant, salvage attempts were not worthwhile [104]. In patients with no implant loosening, salvage was possible [104]. Aggressive measures to stabilize soft tissues in infected elbows include excision of sinus tracts, debridement of thinned skin and exposed bone, and the use of skin grafts, rotation flaps, and muscle pedicle flaps [104]. Infection can be eradicated in 72% to 88% of patients with fair to good results using a two-stage revision technique [104]. Resection arthroplasty had a more predictable outcome in medically "frail" patients and in patients with reduced demands for the elbow [104]. Symptomatic loosening of an elbow prosthesis can be treated by revision using a different type of prosthesis, removal of the prosthesis creating a resection arthroplasty, revision of the remaining bone to create an interposition arthroplasty, or arthrodesis [104]. Eight of 12 implants revised with impaction bone grafting were reported to be intact at 6 years in one series [104]. Strut allograft reconstruction improved Mayo Elbow Performance scores in 21 patients, but complications were frequent (36%) [104]. Allograft-prosthesis constructs were reported to be successful in relieving pain in approximately 70% of patients, although functional gains in approximately 92% of cases [104]. Humeral component fractures occur in 0.65% of implants and ulnar component fractures in 1.2% [104]. Athwal and Morrey reported 26 elbows that had revision because of component fracture, with an average Mayo Elbow Performance score of 82 at 5-year follow-up but frequent complications (62%) [104]. In the absence of infection, satisfactory results can be achieved in as many as 85% of revisions in patients without documented infection and with "sufficient bone stock" and adequate soft tissues [104]. Revision elbow arthroplasty is a salvage procedure that, when successful, is superior functionally to resection arthroplasty or arthrodesis [104]. 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 [74]. Salvage of an intra-articular distal humerus recalcitrant nonunion using 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 [46]. Periprosthetic ulnar fractures around the stem of a loose ulnar component after total elbow arthroplasty usually combine implant loosening and severe bone loss [82]. This salvage technique of implanting the ulnar component into the radius was effective at providing a stable elbow in patients with large ulna bony defects as a result of prosthetic joint infection or periprosthetic fracture [88]. Intramedullary fibula strut bone allograft in a periprosthetic humeral shaft fracture with implant loosening after total elbow arthroplasty can be considered as a treatment option, showing fracture site union, good elbow joint ROM, and pain relief at 10 months postoperatively [90].

Other Considerations: Patients undergoing elective total elbow arthroplasty have slightly higher complication rates than those undergoing shoulder, hip, or knee arthroplasty [4]. Bushing wear occurs in 1.3% of cases [35]. Component fracture occurs in 1.85% of cases [35]. Triceps insufficiency occurs in 2% to 3% of cases [35]. Acute wound complications occur in up to 5.5% of cases [35]. Permanent nerve injury occurs in 2% to 5% of cases [35]. The incidence of neurologic complications associated with the surgical treatment of complex elbow fractures requiring implantation of a radial head prosthesis may be underestimated in the literature [19]. The management of acute unreconstructable fractures of the radial head in unstable elbow injuries with radial head replacement has a high risk of reoperation, with the peak risk appearing within 1 year after implantation [98]. Day et al. showed a 248% increase in primary TEAs performed from 1993 to 2007 and a 500% increase in revision TEAs over that time [35]. A 2005 systematic review described a 33% complication rate and 13% revision rate for TEA [35]. Both open elbow debridement and the OK procedure had excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post-traumatic cases [29]. Treatment options for primary elbow osteoarthritis range from conservative management to open debridement, arthroscopy, and total elbow arthroplasty in selected patients [81]. 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]. Ewald suggested that a history of previous elbow sepsis is an absolute contraindication to prosthetic elbow implant arthroplasty [36]. Coonrad and Morrey considered infection, excessive use of the elbow, ankylosis of the ipsilateral shoulder, and the presence of neurotrophic joints to be contraindications [36]. Kudo et al. concluded that extensive bone loss on either side of the joint and poorly functioning flexor and extensor mechanisms were contraindications [36]. 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 [31].

Complications

Infection (PJI): The reported incidence of infection ranges from 0% to 11.5%, with an average of 5% to 6%, though a high incidence of deep sepsis (9%) attests to the hazardous nature of the procedure [32][128]. Patients with rheumatoid arthritis have higher infection rates than those with posttraumatic sequelae [32]. Persistent wound drainage is highly indicative of deep infection and predicts subsequent component resection [32]. Management generally involves a two-stage revision, which reports an acceptable level of eradication, though well-fixed components may be retained during initial debridement with local antibiotics [32]. Prevention is key; routine administration of vancomycin powder has reduced PJI incidence, whereas surgical helmet systems do not reduce infection rates [129][132].

Aseptic loosening: Loosening of the humeral component has been a principal complication of unconstrained total elbow arthroplasty and was previously the most common cause for revision in semiconstrained prostheses, though this has been reduced with design and technique improvements [32]. In semiconstrained designs, humeral stem loosening remains uncommon at approximately 2% at an average of 7 years [32]. Ulnar component loosening and osteolysis increased with polymethylmethacrylate precoats in the 1990s but decreased after switching to plasma spray surface finishes [32]. The use of shorter (4 inch) stems resulted in an earlier time to revision compared to longer (6 inch) stems [32]. Osteolysis is a multifactorial process similar to that seen in hip and knee replacements, with retrieval studies observing asymmetric thinning, metal-on-metal debris, and particles of polyethylene, cement, and metal [32].

Instability: Instability, defined as dislocation or subluxation, is the most common complication requiring revision of unconstrained prostheses, occurring in 9% to 10% of total elbow arthroplasties [32]. True dislocation occurs in fewer than 5% of unlinked implants and is dependent on surgical technique [32]. Appropriate tensioning of the medial and lateral ligament complexes, along with preservation of the anterior capsule and triceps, helps avoid instability [32].

Periprosthetic fracture: Periprosthetic fracture is a common indication for reoperation alongside aseptic loosening and infection [32]. Humerus and ulna fractures each occur in an average of 5% of cases [32]. Total elbow arthroplasty performed for posttraumatic arthritis is more likely to require reoperation than that performed for other indications [32]. Secondary arthroplasty after failed internal fixation shows a high rate of component loosening potentially related to increased pathology and technical difficulty, though primary arthroplasty for distal humeral fractures produces reliable results regarding revisions [118][120].

Thromboembolism: There is a lack of good quality evidence regarding the risks and benefits of venous thromboembolism prophylaxis in upper limb major joint replacement surgery [110].

Patellar / Extensor-mechanism: Triceps insufficiency and problems occur in an average of 4% of cases [32]. 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 [32].

Stiffness / Arthrofibrosis: Ankylosis occurs in an average of 4% of cases [32].

Nerve palsy: Ulnar neuritis is one of the most commonly encountered complications, with nerve paresthesias occurring in an average of 11% of cases and nerve entrapment in 3% [32]. A 3% incidence of significant ulnar nerve complications compares favorably with systematic reviews [41]. Anterior transposition of the ulnar nerve is a recommended measure to minimize complications [32].

Wound complications: Wound problems occur in an average of 14% of cases [32]. Recommended measures to minimize complications include the use of a straight incision medial to the olecranon tip and drainage of the wound with at least one suction drain [32]. Initial splinting of the elbow in full extension is also recommended [32].

Polyethylene wear: Wear of the polyethylene bearing surface accounts for a minority of revision procedures [32]. Factors associated with bushing wear include younger patient age, male sex, posttraumatic arthritis, preoperative elbow deformity, supracondylar nonunion, and high activity levels [32]. Implant malalignment has been implicated in the development of bearing surface wear [32].

Other Considerations: Primary elbow arthroplasty complication management requires continued advances in exposure, implant design, and surgical technique to improve reliability [1]. The success of total elbow arthroplasty depends 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 overall complication rate has been reported as up to 43%, including an 18% revision rate and 15% "permanent" complications [32]. A recent meta-analysis reported a 13.5% revision rate, with aseptic loosening, infection, and periprosthetic fracture as the most common indications for reoperation [32]. Perioperative mortality is reported at 0.6%, most commonly caused by cardiac complications [32]. Complications occurred in 21% of patients and lead to a decrease in satisfaction and Oxford Elbow Score after 3 years [123]. The overall significant complication rate for modern total elbow arthroplasty is 24.3% ± 5.8% [122]. Surveillance efficacy is higher in primary linked total elbow arthroplasty than in primary shoulder arthroplasty [11]. Complication and revision rates for elbow replacement surgery in tumour patients are comparable to other indications [7]. Most literature consists of retrospective observational studies with small sample sizes and short follow-up [42]. Acceptable implant survival rates were found after 5 and 10 years, with a higher revision rate for the unlinked design and primary TEA due to fracture sequelae [125]. 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 [21]. Lateral resurfacing elbow arthroplasty is a satisfactory alternative with lower complication rates and fewer activity restrictions [15].

Recovery

Light activity (weeks): Patients typically engage in moderate-demand activities within the early postoperative period, with 94% of patients participating in such activities after total elbow arthroplasty [79]. While specific week ranges for desk work or driving are not explicitly quantified in the evidence, the modified posterior approach facilitates early mobilization, allowing for a solid repair of the triceps mechanism and immediate postoperative movement [99].

Full activity (months): Functional improvement is achievable when proper indications are met, including patient understanding of risks and compliance with rehabilitation [18]. Forty percent of patients engage in high-demand activities following the procedure [79]. For patients with surviving implants after hemiarthroplasty for posttraumatic arthritis, 57% achieved good to excellent Mayo Elbow Performance Scores with predictable improvements in range of motion [23].

Complete recovery / outcome plateau (months): The Discovery elbow replacement demonstrated increased function and decreased pain with high survivorship at a mean of 4.1 years [126]. In most cases, elbow function is maintained long-term without implant loosening for Kudo type-5 total elbow arthroplasty in rheumatoid arthritis patients [3]. Total elbow arthroplasty remains a durable option for alleviating pain and restoring motion in the salvage elbow [133].

Rehabilitation protocol: Surgical management of the painful total elbow arthroplasty is refined by a staged protocol utilizing arthroscopic assessment, which directly influences definitive surgical decisions [5]. The modified posterior approach enables early mobilization following total elbow arthroplasty [99]. Treatment of elbow arthritis must be individualized based on etiology, severity, patient age, and functional demands [13].

Functional milestones: Short-term functional outcomes for posttraumatic arthritis or deformities were good according to mean postoperative measurements [10]. Core domains for clinical outcomes have been defined by consensus from patients, carers, and healthcare professionals [17]. With careful patient selection, convertible total elbow arthroplasty provides good to excellent outcomes and substantial improvements in range of movement [16].

Other Considerations: Optimizing outcomes depends on advances in surgical planning, technique, implant design, and materials [2]. Surveillance efficacy is higher in primary linked total elbow arthroplasty than in primary shoulder arthroplasty, supporting appropriate resource allocation [11]. The Discovery elbow replacement shows early clinical results similar to other semi-constrained replacements, warranting continued radiological surveillance for humeral lucency [9]. Survival rates for the Latitude primary total elbow arthroplasty remain low with high complication rates, yet are comparable to other elbow arthroplasties [21]. Obese patients should be counseled regarding their surgical candidacy [34]. Total elbow arthroplasty performed acutely results in satisfactory outcomes and is a consideration for patients at high risk of failing ORIF or nonsurgical management [39]. Resident participation during the procedure is not associated with increased risk for short-term complications or reduced operative efficiency [109].

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. (10.1177/1758573216677200)
• [L5] The continued success of total elbow arthroplasty will depend on advances in surgical planning, technique, implant design, and materials. (10.5435/jaaos-d-25-00473)
• [L3] In most cases, elbow function was maintained in the long-term without loosening of the implant. (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. (10.1016/j.jhsa.2016.07.007)
• [L4] The staged protocol described in the present study, utilizing arthroscopic assessment, has refined the approach to the painful total elbow arthroplasty because it directly influences the definitive surgical management of the patient. (10.1177/1758573215591946)
• [L4] The review discusses various approaches to total elbow arthroplasty and their reported outcomes to assist surgeons in making an informed choice. (10.1177/1758573216682479)
• [L4] The complication and revision rates are comparable to other indications for elbow replacement surgery. (10.1177/17585732211014832)
• [L2] This is the largest systematic review of the complications of total elbow arthroplasty. (10.1177/1758573220905629)
• [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. (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. (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. (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. (10.1016/j.jhsa.2012.12.037)
• [L2] The range of indications for total elbow arthroplasty is broadening; total elbow arthroplasty for acute trauma and osteoarthritis is becoming increasingly more common. (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. (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. (10.1177/1758573221991511)
• [L4] This study defined core domains for the clinical outcomes of elbow replacement obtained by consensus from patients, carers, and healthcare professionals. (10.1302/0301-620x.106b11.bjj-2024-0352.r1)
• [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. (10.2106/00004623-198971040-00006)
• [L4] The incidence of neurologic complications associated with the surgical treatment of complex elbow fractures requiring implantation of a radial head prosthesis may be underestimated in the literature. (10.1016/j.jse.2020.01.086)
• [L4] Survival rates nonetheless remain low and complication rates remain high yet are comparable to those of other elbow arthroplasties. (10.1016/j.jse.2021.08.028)
• [L4] In patients with surviving implants, 57% achieved good to excellent Mayo Elbow Performance Scores with predictable improvement in range of motion. (10.5435/jaaos-d-18-00055)
• [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. (10.1302/2058-5241.2.160064)
• [L4] Both open elbow debridement and the OK procedure had excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post-traumatic cases. (10.1016/j.jse.2022.01.138)
• [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. (10.1016/j.jhsa.2018.11.005)
• [L3] Obese patients being considered for elbow replacement surgery should be counseled accordingly. (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. (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. (10.1016/j.jhsg.2023.05.006)
• [L4] Total elbow arthroplasty carries a higher risk of infection when compared to other major joint replacements. (10.1177/1758573218789341)
• [L4] A 3% incidence of significant ulnar nerve complications after total elbow arthroplasty compares favorably with systematic reviews. (10.1016/j.jhsa.2015.06.107)
• [L4] Most of the literature dealing with elbow arthroplasty consists of retrospective observational studies with small sample sizes and short follow-up. (10.1302/0301-620x.104b10.bjj-2022-0570.r1)
• [L4] The procedure largely preserves elbow kinematics and stability. (10.1016/j.jse.2014.01.042)
• [L5] This study analyzed elbow joint moments in different directions during daily tasks. (10.1016/j.jse.2023.07.042)
• [L4] This approach represents an alternative to the use of hemi or total elbow replacement in younger patients who have undergone multiple prior surgeries. (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. (10.1302/0301-620x.106b10.bjj-2024-0405.r1)
• [L5] In vitro simulation of elbow biomechanics through active cyclic elbow motion at different degrees of shoulder abduction may characterize in vivo performance of total elbow arthroplasty. (10.1016/j.jhsg.2023.08.002)
• [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. (10.1016/j.jse.2021.09.005)
• [L5] Shoulder abduction results in a varus moment at the elbow. (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. (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. (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. (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. (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. (10.1302/0301-620x.95b10.31844)
• [L4] After 15 years, elbows treated with RHA presented signs of arthritis in the majority of patients. (10.1016/j.jse.2025.06.026)
• [L4] The most common mode of failure requiring revision is aseptic loosening, which may be a consequence of the known biomechanical challenges inherent to elbow arthroplasty. (10.1016/j.jse.2025.05.024)
• [L4] Improvement of ROM of the elbow should not be expected. (10.1302/0301-620x.98b8.35025)
• [Case_report] Arthrofibrosis is a well-described complication after total knee arthroplasty, and although this poorly understood condition is known to occur in the elbow, to our knowledge it has not previously been described after TEA. (10.1016/j.jse.2013.10.009)
• [L4] When both the shoulder and elbow are involved, the joint that causes the most pain and disability should be operated on first. (10.2106/00004623-198870010-00031)
• [Case_report] Total elbow arthroplasty can be a successful treatment for end-stage elbow osteoarthritis associated with Paget's disease, provided that preoperative planning accounts for distorted anatomy and potential bone defects. (10.1016/j.xrrt.2023.10.002)
• [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. (10.2106/00004623-198971070-00013)
• [L3] A primary diagnosis of rheumatoid arthritis and a humeral stem with a relatively short flange relative to the stem length significantly contribute to re-revision of total elbow arthroplasty. (10.1016/j.jse.2023.03.003)
• [L4] There is a large variety of pathology and procedures involving the use of various types of allografts in orthopedic reconstructive surgery of the elbow and forearm. (10.1007/s00167-018-5221-y)
• [L4] Ninety-four percent of patients engaged in moderate-demand activities after total elbow arthroplasty, and forty percent engaged in high-demand activities. (10.1016/j.jse.2013.01.023)
• [L5] Overstuffing the radial head prosthesis alters joint kinematics and may lead to pain and degenerative changes. (10.1177/1758573219881772)
• [L4] Treatment options range from conservative management to open debridement, arthroscopy, and total elbow arthroplasty in selected patients. (10.1111/j.1758-5740.2010.00089.x)
• [L4] Periprosthetic ulnar fractures around the stem of a loose ulnar component after total elbow arthroplasty usually combine implant loosening and severe bone loss. (10.2106/jbjs.j.00102)
• [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. (10.1016/j.jse.2023.04.017)
• [L4] This salvage technique was effective at providing a stable elbow in patients with large ulna bony defects as a result of prosthetic joint infection or periprosthetic fracture. (10.1016/j.jse.2020.08.018)
• [L4] The authors' case showed fracture site union, good elbow joint ROM, and pain relief at 10 months postoperatively, indicating that this novel technique can be considered as a treatment option for periprosthetic fracture with implant loosening after total elbow replacement surgery. (10.5397/cise.2020.00213)
• [L4] The current reimbursement model does not adequately account for increased operative time, technical demand, and preand postoperative care associated with revision elbow arthroplasty compared with primary TEA. (10.1016/j.jse.2020.06.004)
• [L4] TEA patients differ from healthy controls in task execution of ADL tasks regarding the functional elbow FE angle over all 8 ADL tasks and in joint load and peak power for the more straining tasks. (10.1016/j.jseint.2024.10.017)
• [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. (10.1177/1758573218768510)
• [L4] The variability in patients' pathoanatomic conditions requires customized surgical treatment aimed at elbow stabilizer reconstruction when the ulnohumeral joint is preserved or aimed at joint replacement in case of severe articular degeneration. (10.1016/j.jse.2019.11.021)
• [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°). (10.1016/j.jseint.2024.10.016)
• [L5] Linking the Latitude total elbow prosthesis results in increased valgus stability. (10.1016/j.jse.2013.02.010)
• [L4] The management of acute unreconstructable fractures of the radial head in unstable elbow injuries with radial head replacement has a high risk of reoperation, with the peak risk appearing within 1 year after implantation. (10.1097/corr.0000000000000876)
• [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. (10.1177/1758573214559319)
• [L4] Revision surgeries are predominantly performed within the first 2 years after implantation, and surgeons should be aware that Workers' Compensation claims and the use of an external fixator in management of the elbow injury are associated with revision surgery. (10.2106/jbjs.20.01231)
• [L4] Although Type-1 and Type-2 prostheses are associated with a high rate of subsidence or loosening of the humeral component, satisfactory clinical results were maintained in elbows followed for ten years or more. (10.2106/00004623-199072030-00006)
• [L4] Younger patients should be counseled regarding the increased risk of requiring further surgery after radial head replacement. (10.1007/s11999-014-3516-y)
• [L3] Resident participation during total elbow arthroplasty is not associated with increased risk for short-term medical or surgical postoperative complications or operative efficiency. (10.1177/17585732211034455)
• [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. (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. (10.1016/j.jhsa.2020.10.034)
• [L4] Patients with elbow arthroplasty had moderate pain, but limited grip strength and ROM, 1 year to 5 years after surgery. (10.1111/j.1758-5740.2010.00081.x)
• [L4] There is concern about early radiologic loosening of the radial component, though this has not resulted in clinical symptoms or implant failure yet. (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. (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. (10.1016/j.jse.2024.03.032)
• [L4] We have reported a 69-year clinical and radiologic follow-up of a previously unknown radial head prosthesis. (10.1016/j.jse.2014.09.030)
• [L3] Heterotopic ossification after total elbow arthroplasty is seen more commonly than previously reported. (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. (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. (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. (10.1016/j.jse.2021.03.063)
• [L1] The overall significant complication rate for modern total elbow arthroplasty is 24.3% ± 5.8%. (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. (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. (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. (10.1016/j.jse.2014.02.001)
• [L4] The Discovery elbow increased function and decreased pain with high survivorship at a mean of 4.1 years. (10.1016/j.jse.2013.12.033)
• [L5] Periprosthetic joint infection after total elbow arthroplasty is relatively common and difficult to eradicate, with prevention being key. (10.1302/0301-620x.106b11.bjj-2024-0549.r1)
• [L4] The high incidence of deep sepsis (9 per cent) attests to the hazardous nature of the elbow-replacement procedure and should warn orthopaedic surgeons to be cautious when recommending this form of treatment. (10.2106/00004623-198365030-00006)
• [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. (10.1016/j.xrrt.2025.06.013)
• [L4] Periprosthetic tissues of total elbow patients who have undergone revision for loosening and osteolysis contain polyethylene, cement, and metal debris. (10.1016/j.jse.2013.02.001)
• [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. (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. (10.1016/j.jse.2007.02.071)

See Also

• Elbow Osteoarthritis
• Cubital Tunnel Syndrome
• Surgical Procedures

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

[5] Arthroscopic management of the painful total elbow arthroplasty. Shoulder & Elbow. 2015. DOI: 10.1177/1758573215591946

[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

[7] Joint replacement surgery for elbow tumours: a systematic review of outcomes. Shoulder & Elbow. 2021. DOI: 10.1177/17585732211014832

[8] A systematic review of the complications of contemporary total elbow arthroplasty. Shoulder & Elbow. 2020. DOI: 10.1177/1758573220905629

[9] Medium-term clinical results of a linked total elbow replacement system. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b10.33815

[10] Semiconstrained Total Elbow Arthroplasty for Posttraumatic Arthritis or Deformities of the Elbow: A Prospective Study. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.03.051

[11] Does long-term surveillance of primary linked total elbow arthroplasty identify failing implants requiring revision?. Shoulder & Elbow. 2024. DOI: 10.1177/17585732241301356

[13] Elbow Arthritis: Current Concepts. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.12.037

[14] Global trends in indications for total elbow arthroplasty: a systematic review of national registries. EFORT Open Reviews. 2020. DOI: 10.1302/2058-5241.5.190036

[15] Long-term results of the lateral resurfacing elbow arthroplasty. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b3.bjj-2017-0865.r1

[16] Functional outcomes and complications following convertible primary total elbow arthroplasty: A single surgeon series. Shoulder & Elbow. 2021. DOI: 10.1177/1758573221991511

[17] Core Outcome Domains for Elbow Replacement (CODER). The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b11.bjj-2024-0352.r1

[18] Total elbow arthroplasty for complete ankylosis of the elbow.. The Journal of Bone & Joint Surgery. 1989. DOI: 10.2106/00004623-198971040-00006

[19] Neurologic complications after surgical management of complex elbow trauma requiring radial head replacement. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.01.086

[21] Mid-term results of the Latitude primary total elbow arthroplasty. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.08.028

[23] Outcomes After Hemiarthroplasty of the Elbow for the Management of Posttraumatic Arthritis: Minimum 2-Year Follow-up. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-18-00055

[24] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Summary and Conclusions.

[25] Current concepts in elbow arthroplasty. EFORT Open Reviews. 2017. DOI: 10.1302/2058-5241.2.160064

[26] Orthopaedic Knowledge Update Sports Medicine 6. Magnetic Resonance Imaging of the Elbow > Annotated References.

[27] Campbell S Operative Orthopaedics 4 Volume Set. GLOBAL APPROACH TO THE ELBOW.

[28] Aaos Comprehensive Orthopaedic Review 3. Elbow Stiffness* > IV. Evaluation.

[29] Long-term survivorship of open débridement and débridement arthroplasty for elbow arthritis: a retrospective chart review. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.138

[31] Total Elbow Arthroplasty. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.11.005

[32] Campbell S Operative Orthopaedics 4 Volume Set. RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS > COMPLICATIONS.

[34] Total Elbow Arthroplasty in Obese Patients. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.00364

[35] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Periprosthetic Fractures About Total Elbow Arthroplasty > Introduction to Periprosthetic Fractures About Total Elbow Arthroplasty.

[36] Campbell S Operative Orthopaedics 4 Volume Set. RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS > TOTAL ELBOW ARTHROPLASTY > INDICATIONS.

[37] Outcomes following hemiarthroplasty of the elbow: minimum 2-year follow-up. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.11.048

[38] Aaos Comprehensive Orthopaedic Review 3. Arthritis and Arthroplasty of the Elbow > I. Osteoarthritis.

[39] Outcomes After Acute Versus Delayed Total Elbow Arthroplasty for the Treatment of Distal Humerus Fractures. Journal of Hand Surgery Global Online. 2023. DOI: 10.1016/j.jhsg.2023.05.006

[40] Scoping review: Diagnosis and management of periprosthetic joint infection in elbow arthroplasty. Shoulder & Elbow. 2018. DOI: 10.1177/1758573218789341

[41] Outcomes After Ulnar Nerve In Situ Release During Total Elbow Arthroplasty. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.06.107

[42] Elbow arthroplasty research methods, outcome domains, and instruments used in clinical outcome studies. The Bone & Joint Journal. 2022. DOI: 10.1302/0301-620x.104b10.bjj-2022-0570.r1

[43] Radiocapitellar prosthetic arthroplasty: a report of 6 cases and review of the literature. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.01.042

[44] Elbow joint loads during simulated activities of daily living: implications for formulating recommendations after total elbow arthroplasty. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.07.042

[46] Salvage of an intra-articular distal humerus recalcitrant nonunion using a pedicled vascularized bone graft. JSES International. 2024. DOI: 10.1016/j.jseint.2024.06.002

[47] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Anatomy > Bony Anatomy.

[48] Elbow kinematics with increased lengthening of a radial head arthroplasty evaluated with dynamic radiostereometric analysis. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b10.bjj-2024-0405.r1

[51] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > ELBOW.

[52] Miller S Review Of Orthopaedics. ELBOW.

[53] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 2Musculoskeletal Trauma Surgery > INJURIES AROUND THE ELBOW.

[54] Active Motion Laboratory Test Apparatus for Evaluation of Total Elbow Prostheses. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2023.08.002

[56] Orthopaedic Knowledge Update Sports Medicine 6. Magnetic Resonance Imaging of the Elbow > Introduction.

[57] Aaos Comprehensive Orthopaedic Review 3. Elbow Injuries in the Athlete* > III. Valgus Extension Overload Syndrome and Posterior Impingement.

[58] The Van Gorder approach for total elbow arthroplasty. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.09.005

[59] Physiological Loading of the Coonrad/Morrey, Nexel, and Discovery Elbow Systems: Evaluation by Finite Element Analysis. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.04.022

[60] Aaos Comprehensive Orthopaedic Review 3. Acute and Recurrent Elbow Instability* > III. Acute Dislocation.

[61] Radiocapitellar stability: the effect of soft tissue integrity on bipolar versus monopolar radial head prostheses. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.10.033

[62] Description of a new surgical approach for elbow arthroplasty: Selective Triceps-On Medial Paraolecranon (STOMP) approach. JSES International. 2025. DOI: 10.1016/j.jseint.2024.12.003

[63] Medial single-window approach to the elbow: a triceps-on technique that does not violate the olecranon bursa. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2025.08.016

[64] Total Elbow Arthroplasty: Elbow Biomechanics and Failure. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.11.020

[65] The effect of excision of the radial head and metallic radial head replacement on the tension in the interosseous membrane. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b10.31844

[67] What happens to the elbow 15 years after a radial head prosthesis? A clinical and imaging long-term follow-up study. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.06.026

[68] Indications for total elbow arthroplasty revision: a systematic review. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.05.024

[69] Short-term clinical results of revision elbow arthroplasty using the Latitude total elbow arthroplasty. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b8.35025

[71] Arthrofibrosis after total elbow arthroplasty: a case report. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.10.009

[72] Arthroplasty of the ipsilateral shoulder and elbow in patients who have rheumatoid arthritis.. The Journal of Bone & Joint Surgery. 1988. DOI: 10.2106/00004623-198870010-00031

[73] Total elbow arthroplasty for elbow osteoarthritis associated with Paget's disease: A case report and review of literature. JSES Reviews, Reports, and Techniques. 2024. DOI: 10.1016/j.xrrt.2023.10.002

[74] Salvage of non-union of supracondylar fracture of the humerus by total elbow arthroplasty.. The Journal of Bone & Joint Surgery. 1989. DOI: 10.2106/00004623-198971070-00013

[75] What factors can reduce the need for repeated revision for humeral loosening in revision total elbow arthroplasty?. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.03.003

[78] There is a role for allografts in reconstructive surgery of the elbow and forearm. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5221-y

[79] Activities after total elbow arthroplasty. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.01.023

[80] Effect of incremental increase in radial neck height on coronoid and capitellar contact pressures. Shoulder & Elbow. 2019. DOI: 10.1177/1758573219881772

[81] Primary Elbow Osteoarthritis: An Updated Review. Shoulder & Elbow. 2011. DOI: 10.1111/j.1758-5740.2010.00089.x

[82] The Surgical Treatment of Periprosthetic Elbow Fractures Around the Ulnar Stem Following Semiconstrained Total Elbow Arthroplasty. Journal of Bone and Joint Surgery. 2011. DOI: 10.2106/jbjs.j.00102

[83] Demographic heterogeneity in valgus angulation of the proximal ulnar canal in relation to the flexion-extension axis. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.04.017

[88] Revision total elbow arthroplasty with the ulnar component implanted into the radius for management of large ulna defects. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.08.018

[90] Intramedullary fibula strut bone allograft in a periprosthetic humeral shaft fracture with implant loosening after total elbow arthroplasty. Clinics in Shoulder and Elbow. 2020. DOI: 10.5397/cise.2020.00213

[91] Trends in reimbursement for primary and revision total elbow arthroplasty. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.06.004

[92] Difference in daily tasks execution and elbow joint load: a comparison between patients after total elbow arthroplasty and healthy controls. JSES International. 2025. DOI: 10.1016/j.jseint.2024.10.017

[93] Clinical outcomes and complications following primary total elbow arthroplasty using the Latitude prosthesis. Shoulder & Elbow. 2018. DOI: 10.1177/1758573218768510

[94] Chronic complex persistent elbow instability: a consecutive and prospective case series and review of recent literature. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.11.021

[95] Evaluating proximal ulnar morphology in relation to the humeral flexion–extension axis. JSES International. 2025. DOI: 10.1016/j.jseint.2024.10.016

[97] Linking of total elbow prosthesis during surgery; a biomechanical analysis. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.02.010

[98] High Risk of Further Surgery After Radial Head Replacement for Unstable Fractures: Longer-term Outcomes at a Minimum Follow-up of 8 Years. Clinical Orthopaedics & Related Research. 2019. DOI: 10.1097/corr.0000000000000876

[99] Modified posterior approach for total elbow replacement. Shoulder & Elbow. 2014. DOI: 10.1177/1758573214559319

[100] Risk Factors for Revision Surgery Following Radial Head Arthroplasty without Cement for Unreconstructible Radial Head Fractures. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01231

[102] Total elbow arthroplasty with a non-constrained surface-replacement prosthesis in patients who have rheumatoid arthritis. A long-term follow-up study.. The Journal of Bone & Joint Surgery. 1990. DOI: 10.2106/00004623-199072030-00006

[103] A Humeral Replacement Prosthesis for the Elbow: RESULTS IN TEN ELBOWS.. The Journal of Bone and Joint Surgery. American Volume. 1974.

[104] Campbell S Operative Orthopaedics 4 Volume Set. RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS > SALVAGE > REVISION ELBOW ARTHROPLASTY.

[105] Radial Head Replacement for Acute Complex Fractures: What Are the Rate and Risks Factors for Revision or Removal?. Clinical Orthopaedics & Related Research. 2014. DOI: 10.1007/s11999-014-3516-y

[106] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Biomechanics > Motion.

[107] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Elbow Degenerative Conditions and Nerve Disorders > Evaluation.

[108] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Biomechanics > Clinical Examination.

[109] Total elbow arthroplasty cases involving orthopaedic residents do not affect short-term postoperative complications. Shoulder & Elbow. 2021. DOI: 10.1177/17585732211034455

[110] Is venous thromboembolism prophylaxis beneficial in upper limb major joint replacement surgery? A systematic review. Shoulder & Elbow. 2020. DOI: 10.1177/1758573219896279

[111] Results of Linked Convertible Total Elbow Arthroplasty for the Management of Distal Humeral Fractures in the Elderly. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2020.10.034

[112] Pain and Function in Patients with Rheumatic Disease and Elbow Arthroplasty: Clinical and Methodological Aspects. Shoulder & Elbow. 2010. DOI: 10.1111/j.1758-5740.2010.00081.x

[113] Early results of Latitude primary total elbow replacement with a minimum follow-up of 2 years. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.06.037

[114] Morphometry of the radiocapitellar joint: is humeral condyle diameter a reliable predictor of the size of the radial head prosthesis?. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.01.017

[115] Outcomes of total elbow arthroplasty in the treatment of distal humeral fractures in the elderly: a retrospective cohort comparison between primary arthroplasty and arthroplasty secondary to failed internal fixation. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.03.032

[116] Sixty-nine-year follow-up of a McKee radial head arthroplasty. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.09.030

[117] Heterotopic ossification following total elbow arthroplasty. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b6.bjj-2017-0535.r2

[118] Failed Open Reduction And Internal Fixation For Elbow Fractures Converted To Total Elbow Arthroplasty. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.02.051

[120] Arthroplasty as primary treatment for distal humeral fractures produces reliable results with regards to revisions and adverse events: a registry-based study. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.07.035

[121] Survival Analysis and Cementation Criteria for Success on Total Elbow Arthroplasty – A Mono-Center Analysis of 31 Cases. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.03.063

[122] Complications of total elbow replacement: A systematic review. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.08.026

[123] The influence of short-term complications on the outcomes of total elbow arthroplasty. JSES International. 2021. DOI: 10.1016/j.jseint.2021.02.015

[124] Interobserver reliability of radiographic assessment after radial head arthroplasty. Shoulder & Elbow. 2017. DOI: 10.1177/1758573217719088

[125] Implant survival after total elbow arthroplasty: a retrospective study of 324 procedures performed from 1980 to 2008. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.02.001

[126] A prospective multicenter clinical study of the Discovery elbow. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.12.033

[127] Management of the infected total elbow arthroplasty. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b11.bjj-2024-0549.r1

[128] Infection after total elbow arthroplasty.. The Journal of Bone & Joint Surgery. 1983. DOI: 10.2106/00004623-198365030-00006

[129] The use of vancomycin powder in total elbow arthroplasty; can we decrease infection risk?. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.06.013

[130] Characterization of wear debris in total elbow arthroplasty. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.02.001

[132] Surgical helmet systems do not reduce the incidence of periprosthetic joint infections in elbow arthroplasty: results from the New Zealand National Joint Registry, 2000-2023. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.11.034

[133] Ten To Thirty-One Year Survival Analysis Of Total Elbow Arthroplasty With The Coonrad And Coonrad-Morrey Prosthesis. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.02.071