முழங்கை மூட்டு மாற்று அறுவை சிகிச்சை (Elbow Arthroplasty)

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

Overview¶

• Total elbow arthroplasty is a surgical option for end-stage elbow arthritis [69].
• The indications for total elbow arthroplasty are expanding from rheumatoid arthritis to osteoarthritis, post-traumatic arthritis, and acute fractures [69].
• The range of indications for total elbow arthroplasty is broadening [18].
• Total elbow arthroplasty for acute trauma and osteoarthritis is becoming increasingly more common [18].
• Total elbow arthroplasty is a durable and effective option in alleviating pain and restoring motion in the salvage elbow [46].
• 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 [39].
• Patients undergoing elective total elbow arthroplasty have slightly higher complication rates than those undergoing shoulder, hip, or knee arthroplasty [5].
• Complications occurred in 21% of patients undergoing total elbow arthroplasty [48].
• Complications in total elbow arthroplasty lead to a decrease in satisfaction and Oxford Elbow Score after 3 years [48].
• There are no significant differences in satisfaction or Oxford Elbow Score at 1-year or 5-year follow-up despite complications [48].
• Survival rates for total elbow arthroplasty remain low [24].
• Complication rates for total elbow arthroplasty remain high [24].
• Complication rates for total elbow arthroplasty are comparable to those of other elbow arthroplasties [24].
• The complication and revision rates for joint replacement surgery for elbow tumours are comparable to other indications for elbow replacement surgery [19].
• 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].
• The continued success of total elbow arthroplasty will depend on advances in surgical planning, technique, implant design, and materials [7].
• Most of the literature dealing with elbow arthroplasty consists of retrospective observational studies with small sample sizes and short follow-up [26].
• Surveillance efficacy is higher in primary linked total elbow arthroplasty than primary shoulder arthroplasty [6].
• Higher surveillance efficacy in primary linked total elbow arthroplasty supports appropriate resource allocation for elbow arthroplasty surveillance [6].

Anatomy & Pathophysiology¶

Bony Anatomy¶

• The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that provide bony stability [112].
• The ulnohumeral joint is formed by the articulation of the trochlea with the ulna within the greater sigmoid notch [112].
• The ulnohumeral articulation provides highly congruent anatomy through almost 180° of articular contact, with the exception of a bare area in the greater sigmoid notch devoid of cartilage [112].
• The radiocapitellar joint is formed by the articulation of the capitellum and the radial head [112].
• The proximal radioulnar joint holds the radius in close approximation to the ulna via the annular ligament [112].
• The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [112].
• The distal humeral articulation is angled 30° from the longitudinal axis of the humerus [112].
• 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 [112].
• The ulna bends approximately 8° medially at a point 8 cm from the tip of the olecranon [112].
• The articulation to the tip of the coronoid process is approximately 30° from the long axis of the ulna in the sagittal plane [112].
• The articular surface of the distal humerus is angled 30 degrees anterior to the humeral shaft axis [54].
• The distal humerus consists of medial and lateral columns [54].
• The trochlea possesses a 300-degree arc of cartilage [55].
• The medial column of the distal humerus diverges from the humeral shaft at a 45-degree angle [55].
• The lateral column of the distal humerus diverges from the humeral shaft at a 20-degree angle [55].
• In full extension, 60% of axial load is transmitted through the radiocapitellar joint [54].
• The normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [54].
• The plane through the ridge of the greater sigmoid notch of a healthy proximal ulna provides a more reliable anatomical landmark to estimate the position of the elbow flexion-extension axis compared to the posterior surface [161].
• Anatomical variations at the distal humerus and proximal ulna affect the alignment of components during total elbow arthroplasty [189].
• The valgus angulation of available total elbow arthroplasty designs is discordant with the mean native valgus angulation, and the implants' valgus laxity does not cover the variability in the studied population [154].

Ligamentous Anatomy¶

• Elbow stability is determined by primary stabilizers, which include the ulnohumeral articulation, the medial ulnar collateral ligament (MUCL), and the lateral ulnar collateral ligament (LUCL) complex [53].
• Secondary stabilizers of the elbow include the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [53].
• The medial collateral ligament complex comprises anterior, posterior, and transverse bundles [54].
• The anterior bundle of the medial collateral ligament is the primary restraint to valgus stress within functional elbow range of motion [54].
• The posterior bundle of the medial collateral ligament is the primary restraint to valgus stress with the elbow in maximal flexion [54].
• Stability in full extension is provided by the medial collateral ligament, joint capsule, and ulnohumeral articulation [54].
• The anterior oblique ligament of the medial collateral ligament complex is the strongest component and the primary stabilizer to valgus stress [121].
• The anterior oblique ligament originates on the anterior-inferior edge of the medial epicondyle and inserts on the sublime tubercle of the ulna [121].
• The anterior band of the medial collateral ligament is taut in extension, while the posterior band is tight in flexion [121].
• The olecranon stabilizes valgus stress to the elbow, and excessive resection places the medial collateral ligament at risk [121].
• Surrounding elbow musculature, specifically the flexor digitorum superficialis and flexor carpi ulnaris, provides a dynamic stabilizing force across the elbow joint [121].
• The lateral ulnar collateral ligament origin center is located 10.7 mm from the lateral epicondyle [111].
• The lateral ulnar collateral ligament insertion is located 3.3 mm from the apex of the supinator crest [111].
• An elbow with medial ulnar collateral ligament insufficiency experiences an increase in valgus angle and a propensity for the ulna to go into internal rotation under valgus stress [186].

Range of Motion and Biomechanics¶

• The normal range of elbow flexion and extension is 0 to 150 degrees [54].
• The normal range of forearm pronation and supination is 80 to 85 degrees in each direction [54].
• 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) [187].
• The ulnohumeral joint allows for flexion and extension of the elbow [55].
• The radiocapitellar joint allows for forearm rotation [55].
• Shoulder abduction results in a varus moment at the elbow [129].
• In vitro simulation of elbow biomechanics through active cyclic motion at different degrees of shoulder abduction may characterize the in vivo performance of total elbow arthroplasty [56].
• Elbow joint loads during simulated activities of daily living vary based on the specific task and direction of motion [110].
• Total elbow arthroplasty patients differ from healthy controls in task execution regarding functional elbow flexion-extension angle, joint load, and peak power for more straining tasks [160].

Pathophysiology of Arthritis¶

• Symptomatic primary osteoarthritis of the elbow affects 2% of the population [34].
• Primary osteoarthritis of the elbow typically presents at an average age of 50 years, with a range of 20 to 70 years [34].
• Men are affected by primary osteoarthritis of the elbow more often than women at a 4:1 ratio [34].
• Hand dominance and strenuous manual labor are associated with primary osteoarthritis of the elbow [34].
• Secondary causes of elbow osteoarthritis include trauma, osteochondritis dissecans, and synovial osteochondromatosis [34].
• Osteoarthritis of the elbow is characterized by osteophyte formation, capsular contracture, and loose bodies, often with relative preservation of the joint space [34].
• Periarticular hypertrophic osteophytes act as a mechanical block at the end ranges of flexion and extension in elbow osteoarthritis [34].
• Osteoarthritis of the elbow typically involves the radiocapitellar joint articular cartilage preferentially, with relative preservation of the ulnohumeral articular surfaces [34].
• Ulnar neuropathy is present in up to 50% of patients with elbow osteoarthritis [34].
• The pathoanatomy of valgus extension overload syndrome includes chondrosis, osteophyte development on the posteromedial olecranon and humerus, and loose bodies [62].
• During throwing, the olecranon is repeatedly and forcefully driven into the olecranon fossa, exerting shear forces on the medial aspect of the olecranon tip and the olecranon fossa [62].
• Medial ligamentous laxity commonly exacerbates valgus extension overload syndrome [62].
• The ulnohumeral articulation contributes to elbow stability, and olecranon resection increases valgus angulation and medial collateral ligament strain during valgus stress [62].

Implant Biomechanics and Failure Mechanisms¶

• Recent changes in elbow arthroplasty device design and implantation methods are driven by biomechanical and clinical outcome-based research to better reproduce elbow kinematics [16].
• Cementing a nonanatomic hinge that may not rely on native elbow soft tissue support can result in a troubling biomechanical environment [139].
• Loading increases for all malaligned implant positions tested in total elbow arthroplasty [209].
• Combinations of internal-external and varus-valgus malrotations that preserve the line of action of the elbow flexors result in lower loads than combinations that do not [209].
• Active patients with osteoarthritic or post-traumatic arthritic elbows experience greater levels of stress at the coupling mechanism with a semi-constrained total elbow arthroplasty than rheumatoid patients [106].
• Failure of the central axis mechanism in Coonrad-Morrey total elbow arthroplasty occurred at 1.5 to 4 years post-implantation in osteoarthritic and post-traumatic patients [106].
• No central axis failure was noted in rheumatoid patients during the same period as the osteoarthritic/post-traumatic failures [106].
• Valgus stress on the elbow joint may contribute to implant failures in Kudo type 5 total elbow arthroplasty [94].
• The most common mode of failure requiring revision in total elbow arthroplasty is aseptic loosening, which may be a consequence of known biomechanical challenges inherent to the procedure [71].
• The kinematics of the elbow deviate increasingly from those of the native joint with a 2 mm to 4 mm lengthening of the radius in radial head arthroplasty [113].
• Overstuffing the radial head prosthesis alters joint kinematics and may lead to pain and degenerative changes [153].
• 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 [145].
• The radial head prosthesis mimics the mechanics of the native radial head in terms of mean contact area, mean contact pressure, and peak contact pressure [163].
• Different patterns of contact pressure and area curves during elbow flexion-extension are observed between native radial heads and prostheses [163].
• From a biomechanical perspective, the enhancement of elbow stability with a monopolar radial head prosthesis is superior to that with a bipolar design [132].
• The bicipital tuberosity and distal radius are unreliable landmarks for radial head implant alignment as they show no consistent rotational relationship with the maximum diameter of the radial head [188].
• The posterior flange of a novel total elbow arthroplasty design withstood static and dynamic forces greater than what is expected during in vivo use [165].
• Coronoid impingement causing early failure of total elbow arthroplasty can be minimized by placing the elbow in deep flexion during surgery and removing any impinging anterior structures [176].

Classification¶

• The range of indications for total elbow arthroplasty is broadening, with use for acute trauma and osteoarthritis becoming increasingly more common [18].
• Total elbow arthroplasty is indicated for the treatment of distal humerus fractures in patients aged 65 years or older [107].
• Total elbow arthroplasty is indicated for the management of simple open distal humeral fractures [216].
• Total elbow arthroplasty is indicated for patients with posttraumatic arthritis or deformities of the elbow [13].
• Total elbow arthroplasty is indicated for patients with rheumatoid arthritis [4].
• Total elbow arthroplasty is indicated for the treatment of elbow tumours [19].
• Total elbow arthroplasty is indicated for the treatment of distal humeral fractures in the elderly, including as a primary procedure or secondary to failed internal fixation [107].
• The most common mode of failure requiring revision total elbow arthroplasty is aseptic loosening [71].
• Revision total elbow arthroplasty is indicated in the situation of bone loss, provided there is no infection or instability [101].
• Surgical management of periprosthetic joint infection in total elbow arthroplasty includes debridement and irrigation with implant retention (DAIR), single-stage revision, and two-stage revision [208].
• Debridement and irrigation with implant retention (DAIR) is most successful in patients with acute infection, a functioning triceps, an intact soft tissue envelope, and stable implants [208].
• Patients with a sinus tract, polymicrobial infections, or culture-negative infections are at increased risk of persistent infection following debridement and irrigation with implant retention (DAIR) [208].
• The Mayo Classification is used to classify periprosthetic fractures in total elbow arthroplasty [208].

Clinical Presentation¶

History and Symptoms¶

• Patients with primary elbow osteoarthritis typically present with loss of terminal extension and flexion and painful catching, clicking, or locking of the elbow [34].
• Pain in primary elbow osteoarthritis is typically noted at the end ranges of motion rather than through the midrange [34].
• Night pain is not typical for primary elbow osteoarthritis; if present, an inflammatory cause of the arthritis should be considered [34].
• The degree of disability caused by elbow osteoarthritis depends on the patient’s vocation and physical disability [34].
• A thorough history is invaluable for understanding the type of disease process and the degree that the condition affects the patient [194].
• Understanding whether the patient has pain throughout the arc of motion or only at terminal limits is of paramount importance [194].
• Associated mechanical symptoms or instability must be evaluated during the history [194].
• Associated conditions such as cubital tunnel syndrome must be considered and evaluated to provide optimal recommendations on management [194].
• The location, quality or type, context, duration, and severity of elbow pain are important for understanding pathology and focusing the physical examination [197].
• Prior treatments including surgical interventions and injections help in making the correct diagnosis [197].
• Determining the symptom trajectory (whether pain is getting better, worse, or remaining constant) is helpful when considering intervention [197].
• For elbow stiffness, the history should include the duration of the contracture, initial injury, previous surgical procedures, trials of splinting/therapy/injections, complications of surgery, and the patient’s work/life demands and goals [31].

Physical Examination¶

• The function of the upper extremity (shoulder, wrist, and hand) should be assessed during the physical examination for elbow stiffness [31].
• The soft tissue surrounding the elbow should be examined for previous skin incisions, grafts, eschar, or infection [31].
• Active and passive flexion, extension, supination, and pronation should be evaluated using a goniometer for accurate measurement [31].
• The contralateral elbow should be examined for comparison when assessing range of motion [31].
• 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 [31].
• Pain during the mid-arc of motion is more common with intrinsic disease and may not improve with contracture release alone [31].
• The ulnar nerve is of utmost importance during examination due to its anatomic proximity to the elbow [31].
• Electromyography and nerve conduction velocity studies should be performed if there is any question about neurologic dysfunction [31].
• An assessment for ulnar nerve subluxation should be performed, as subluxation is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [31].
• If a history of prior surgical procedures exists, verify if the ulnar nerve has been transposed [31].
• Loss of full extension is the first motion altered by most pathology and the last to be regained [192].
• 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 [192].
• Rupture of the triceps tendon or neurologic conditions should be suspected if there is loss of active extension [192].
• Loss of passive extension is a sensitive but nonspecific sign of an intra-articular process [192].
• The simple extension test has a sensitivity of 97% and a negative predictive value of 98% [192].
• The specificity of the simple extension test is 69%, with a positive predictive value of 63% [192].
• The examiner should record both active and passive values for elbow motion [192].
• Any significant difference between active and passive ranges of motion suggests pain or motor dysfunction as the cause [192].
• 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 [192].
• The upper extremity should be examined from the side with the hand in full supination to adequately assess for contracture [192].
• A careful assessment of any compromised motion at the shoulder or wrist should be made [192].
• Flexion contractures of less than 45° may have little practical significance, although patients may be concerned about the cosmetic appearance [192].
• To perform 90% of required daily activity, 50° of pronation and supination are required [192].
• Pronation is the most important function on the dominant side for eating and writing [192].
• Loss of pronation is compensated by shoulder abduction [192].
• A loss of supination of the nondominant side may significantly hinder personal hygiene needs, accepting objects, and opening door handles [192].
• Tasks involving supination are poorly compensated by shoulder or wrist function [192].
• The radial head is driven into the capitellum with pronation by the screw-home mechanism [192].
• When combined with flexion or extension under a load as in the radiocapitellar load test, reproduction of radiocapitellar pain signals a problem with the joint [192].
• Crepitus can be noted with the radiocapitellar load test [192].
• Inspection should check for prior surgical incisions and joint effusion at the lateral soft spot in primary elbow osteoarthritis [34].
• Pain is usually felt at the end ranges of flexion and extension rather than throughout the arc in primary elbow osteoarthritis [34].
• Forearm rotation is relatively preserved until later in the disease process of primary elbow osteoarthritis [34].
• Ulnar neuropathy is present in up to 50% of patients with primary elbow osteoarthritis [34].
• Physical examination of the elbow should focus on functional anatomy, including inspection, palpation, range of motion, strength, stability, and special tests [197].
• Examination elements are dynamic, and adequate assessment oftentimes combines examination maneuvers to fully elucidate the elbow pathology [197].

Imaging¶

• Radiographs should always be obtained for the evaluation of elbow stiffness [31].
• AP, lateral, and oblique radiographs are standard for elbow stiffness, with serial radiography as follow-up when heterotopic ossification is present [31].
• 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 [31].
• CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [31].
• Three-dimensional CT is used to check for heterotopic ossification [31].
• CT is not necessary when the stiffness is entirely soft-tissue related [31].
• If any joint incongruity or abnormal bony anatomy is present, CT is beneficial [31].
• MRI can be used to evaluate ligaments and tendons, but it is rarely indicated for elbow stiffness [31].
• Plain radiographs should be obtained during the initial workup to evaluate the articular surface and bony anatomy [194].
• CT scans with 3D reconstructions may be useful for evaluating the extent and location of disease and for surgical planning [194].
• MRI may be useful to evaluate the status of the soft tissues including the medial and lateral collateral ligamentous complexes [194].
• Electromyography and nerve conduction studies may be useful to evaluate the degree of nerve compression and contribution to the elbow pain and/or dysfunction [194].
• Standard AP and lateral radiographs should be obtained for primary elbow osteoarthritis [34].
• Radiographs for primary elbow osteoarthritis typically show osteophyte formation at the coronoid process (anterior and medial), coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa [34].
• Joint spaces at the ulnohumeral joint are usually preserved in primary elbow osteoarthritis [34].
• Joint spaces at the radiocapitellar joint are mildly narrowed in primary elbow osteoarthritis [34].
• Loose bodies may be evident on radiographs, which typically underestimate the number present [34].
• CT may be useful for surgical planning in primary elbow osteoarthritis, allowing a detailed assessment of osteophytes and the presence of loose bodies [34].

Investigations¶

History and Physical Examination¶

• History for elbow stiffness evaluation includes duration of contracture, initial injury, previous surgical procedures, trials of splinting/therapy/injections, surgical complications, and patient work/life demands/goals [31].
• Physical examination for elbow stiffness requires assessment of upper extremity function (shoulder, wrist, hand) and inspection of soft tissues for previous skin incisions, grafts, eschar, or infection [31].
• Range of motion assessment for elbow stiffness involves evaluating active and passive flexion, extension, supination, and pronation using a goniometer, with the contralateral elbow examined for comparison [31].
• In elbow stiffness, if flexion is less than 90° to 100°, the posterior bundle of the medial collateral ligament is contracted and must be released to restore flexion [31].
• Pain assessment during range of motion distinguishes mid-arc pain (more common with intrinsic disease) from terminal end pain [31].
• Neurovascular examination for elbow stiffness prioritizes the ulnar nerve due to its anatomic proximity, noting that the posterior bundle of the medial collateral ligament forms the floor of the cubital tunnel [31].
• Electromyography and nerve conduction velocity studies are indicated if there is any question about neurologic dysfunction in the elbow [31].
• Assessment for ulnar nerve subluxation is required, as subluxation is a relative contraindication for arthroscopic procedures due to risk of iatrogenic nerve injury [31].
• History of prior surgical procedures requires verification of whether the ulnar nerve has been transposed [31].
• Patients with primary elbow osteoarthritis typically present with loss of terminal extension and flexion, painful catching/clicking/locking, and pain at end ranges of motion rather than midrange [34].
• Night pain is not typical for primary elbow osteoarthritis; if present, an inflammatory cause should be considered [34].
• Physical examination for primary elbow osteoarthritis includes inspection for prior surgical incisions and joint effusion at the lateral soft spot [34].
• A complete neurovascular examination of the radial, median, ulnar, and anterior and posterior interosseous nerves should be performed before and after treatment of elbow injuries [55].
• The normal elbow has a range of motion from 0° to 140° from extension to flexion and 75° to 85° in pronation and supination [53].
• A functional arc for the elbow is 100° for flexion/extension and forearm rotation [53].
• Elbow stability is determined by primary stabilizers (ulnohumeral articulation, MUCL, LUCL) and secondary stabilizers (radiocapitellar articulation, common flexor/extensor tendons, joint capsule) [53].
• Physical examination of the elbow is directed by history and the location of pain in the anterior, posterior, medial, or lateral compartments [53].
• Neurovascular status should be documented before and after elbow reduction for acute dislocation [130].
• Open injuries and compartment syndrome requiring immediate surgical treatment should be ruled out during physical examination for acute elbow dislocation [130].

Imaging¶

• Standard radiographs for elbow evaluation include AP, lateral, and oblique views, with serial radiography used for follow-up when heterotopic ossification is present [31].
• Primary bony landmarks on elbow radiographs include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [31].
• CT is helpful for assessing malunion architecture and the location/pattern of osteophytes or loose bodies in elbow stiffness [31].
• Three-dimensional CT is used to check for heterotopic ossification in the elbow [31].
• CT is not necessary for elbow stiffness when the condition is entirely soft-tissue related, but is beneficial if joint incongruity or abnormal bony anatomy is present [31].
• MRI can be used to evaluate ligaments and tendons in the elbow but is rarely indicated [31].
• Radiographs for primary elbow osteoarthritis typically show osteophyte formation at the coronoid process, coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa [34].
• In primary elbow osteoarthritis, joint spaces at the ulnohumeral joint are usually preserved, while those at the radiocapitellar joint are mildly narrowed [34].
• Radiographs typically underestimate the number of loose bodies present in primary elbow osteoarthritis [34].
• CT may be useful for surgical planning in primary elbow osteoarthritis by allowing detailed assessment of osteophytes and loose bodies [34].
• Plain AP and lateral radiographs are necessary to document congruent reduction after acute elbow dislocation [130].
• Oblique views may be useful to identify periarticular fractures in acute elbow dislocation [130].
• CT is useful to identify associated osseous injury in acute elbow dislocation [130].
• CT or MRI should be considered to identify potential incarcerated osteocartilaginous fragments if an elbow reduction is incongruous [130].
• Radiographs, CT, ultrasonography, and MRI each have a role in elbow imaging [122].
• CT can be helpful in identifying mineralized intra-articular loose bodies or delineating the anatomy of a complex intra-articular fracture [122].
• Ultrasonographic soft-tissue evaluation is most useful for evaluating the distal biceps and common flexor/extensor tendons in the elbow [122].
• Ultrasonography allows dynamic imaging, which may be useful for evaluating ulnar nerve subluxation or a snapping triceps [122].
• MRI is the imaging modality best suited for evaluating soft-tissue structures in the elbow, including ligaments, tendons, cartilage, and nerves [122].
• Conventional MRI sequences for the elbow should be obtained in all three planes using T1-weighted and fluid-sensitive sequences (STIR or T2-weighted with fat suppression) [122].
• Magnetic resonance arthrography is particularly beneficial for evaluating osteochondral lesions, loose bodies, and ulnar collateral ligament injury in a throwing athlete [122].
• Coronal MRI studies of the elbow should be obtained along a line connecting the medial and lateral epicondyles, with sagittal studies perpendicular to the coronal studies [122].
• 3-Tesla MRI units can generate high signal-to-noise ratios and show normal anatomy better than 1.5-Tesla units, but caution is necessary as they can show mild signal alterations of tendons, ligaments, and nerves that may not be symptomatic [122].
• Ligaments and tendons appear anechoic (black) on all MRI imaging sequences [122].
• Tears in elbow tendons or ligaments are diagnosed by identifying signal in the tissue that brightens to the level of simple fluid, representing focal discontinuity of fibers [122].
• AP, lateral, oblique, and axillary views of the elbow may reveal posteromedial olecranon osteophytes and/or loose bodies in valgus extension overload syndrome [62].
• CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [62].
• 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].
• CT scan with three-dimensional reconstruction is helpful for preoperative planning of intercondylar fractures [55].
• Effusions in the elbow can be discerned by swelling between the lateral epicondyle and the olecranon [55].
• With the elbow in 90 degrees of flexion, the medial condyle, lateral condyle, and olecranon form a palpable triangle used for assessing fractures, dislocations, or effusions [55].
• Radiographic evaluations are essential when diagnosing an OCD lesion of the elbow, though important aspects may be better seen with MRI [131].
• Plain radiographs are still most often employed for medial epicondyle fractures, though MRI may be used to identify partial or periosteal sleeve avulsions [136].
• Oblique and axial views have been proposed to improve measurement accuracy of displacement in medial epicondyle fractures [136].
• Comparison views can be useful in the diagnosis of Little Leaguer’s elbow [135].
• MRI studies in symptomatic youth athletes with Little Leaguer’s elbow often show edema at the distal humerus or medial epicondyle apophysis [135].
• Preseason MRI abnormalities in youth baseball players were associated with year-round play, private coaching, and loss of shoulder internal rotation [135].
• Postseason MRI evaluation of dominant elbows revealed abnormalities in 46% of Little League players [135].

Treatment¶

Indications and Patient Selection¶

• The primary indications for total elbow arthroplasty are pain and/or instability [90].
• Deformity and dysfunction without pain are not indications for surgery [90].
• An unreconstructible distal humeral fracture in an elderly patient is an increasingly common indication for total elbow arthroplasty [90].
• 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 for total elbow arthroplasty [90].
• Elderly patients with end-stage posttraumatic sequelae are acceptable candidates for total elbow replacement [90].
• Bony or fibrous ankylosis with the elbow in a poorly functioning position is an indication for elbow arthroplasty [90].
• In patients with rheumatoid arthritis, arthroplasty should be considered only after medical treatment has failed and the disease has advanced to show bony changes [90].
• The range of indications for total elbow arthroplasty is broadening, with total elbow arthroplasty for acute trauma and osteoarthritis becoming increasingly more common [18].
• 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 [69].
• Treatment of elbow arthritis must be individualized based on etiology, severity, patient age, and functional demands [32].
• Nonsurgical management may provide relief in early stages of elbow arthritis [32].
• 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].
• Treatment options for primary elbow osteoarthritis range from conservative management to open debridement, arthroscopy, and total elbow arthroplasty in selected patients [84].
• Osteocapsular debridement is an effective surgical treatment option for patients with symptomatic primary elbow osteoarthritis who have failed conservative management [199].
• 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 [25].
• Elbow hemiarthroplasty is an option for young or active patients with end-stage posttraumatic arthritis who are unwilling to accept activity limitations [14].
• Elbow hemiarthroplasty is a viable option for complex distal humeral fractures in select patients, offering functional outcomes comparable to total elbow arthroplasty while potentially avoiding complications related to the ulnar component [88].
• 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 [91].
• 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 [138].
• A pedicled vascularized bone graft approach represents an alternative to the use of hemi or total elbow replacement in younger patients who have undergone multiple prior surgeries for intra-articular distal humerus recalcitrant nonunion [15].
• Obese patients being considered for elbow replacement surgery should be counseled accordingly [10].
• 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 [89].
• 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 [90].
• The best candidate for total elbow replacement has been described as a patient with severely painful and disabling rheumatoid arthritis with altered articular architecture [90].
• 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].
• Elbow arthrodesis 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].
• 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].
• 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].
• Total elbow replacement restored the bone defect and offered an excellent functional outcome in combination with attachment tube soft tissue reconstruction for giant-cell tumor of bone after denosumab treatment [172].

Implant Selection and Design¶

• 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 [90].
• 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 [90].
• 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 [90].
• Ewald suggested that one absolute contraindication to prosthetic elbow implant arthroplasty is a history of previous elbow sepsis [90].
• Ewald considered a previous fascial or other interpositional arthroplasty and previous hinged arthroplasty to be absolute contraindications to the use of the capitellocondylar device [90].
• Relative contraindications to the use of an unconstrained resurfacing arthroplasty included excessive bone loss, as in giant rheumatoid cysts, deficiency of the trochlear notch of the ulna, and posttraumatic or degenerative arthritis [90].
• Coonrad and Morrey considered infection, excessive use of the elbow, ankylosis of the ipsilateral shoulder, and the presence of neurotrophic joints to be contraindications [90].
• Kudo et al. concluded that extensive bone loss on either side of the joint and poorly functioning flexor and extensor mechanisms were contraindications [90].
• Morrey et al. reported that no consistently reliable total prosthetic arthroplasty is available for patients with posttraumatic degenerative arthritis in the elbow [90].
• In these salvage situations, posttraumatic degenerative arthritis does not always represent an absolute contraindication to total elbow arthroplasty [90].
• 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 [89].
• 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, but not so much as to allow instability [89].
• Clinical success and technical simplicity have led to the popularity of the semiconstrained design [89].
• Convertible models allow simpler conversion from unconstrained to semiconstrained implants [89].
• A systematic review in 2005 including 86 articles showed 78% good–excellent results for TEA, which were more common for semiconstrained implants (82%) versus unlinked (78%) versus fixed hinge (73%) [89].
• At the time of the 2005 systematic review, the literature described a 33% complication rate and 13% revision rate [89].
• A similar study in 2011 suggested progress with an overall 24.3% complication rate which was slightly lower for linked (25.9%) versus unlinked (27.2%) prostheses [89].
• Linked implants did not have higher clinical loosening (5.2%) compared with unlinked (5.2%) [89].
• Clinical instability was lower in linked (1.4%) versus unlinked (4.9%) implants [89].
• The most recent review showed decreased aseptic loosening of linked compared with unlinked (p < 0.005) prostheses [89].
• Revision was lower for linked (13.8%) versus unlinked (16.3%; p = 0.015) [89].
• These results support the use of semiconstrained implants especially in low-demand elderly patients [89].
• Advances in technique and implant design spawned good results in appropriately selected patients, namely low-demand elderly patients with severe pain secondary to inflammatory arthropathy [89].
• Sanchez-Sotelo and colleagues published their results of 461 TEAs done for RA, in which 80% were female, with an average age of 64 years and a BMI of 25 (only 15% had a BMI >30) [89].
• This niche patient population had an 11% (71/461) revision rate with revision-free implant survivorship of 92% at 10 years, 83% at 15 years, and 68% at 20 years [89].
• An analysis of the New York State registry showed a significant increase in the use of TEAs from 93 in 1997 to 134 in 2006 (p < 0.01) [89].
• The shift in indications evolved from 43% traumatic and 48% inflammatory arthropathy in 1997 to 69% traumatic and 19% inflammatory arthropathy in 2006 (p < 0.01) [89].
• 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 which is expected to continue at 12.8% per year [89].
• Elbow arthroplasty using a cemented linked semiconstrained implant provides satisfactory clinical results in the treatment of rheumatoid arthritis with a reasonable rate of survivorship free of mechanical failure at 20 years [168].
• In most cases, elbow function was maintained in the long-term without loosening of the implant for Kudo type-5 total elbow arthroplasty for patients with rheumatoid arthritis [4].
• 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 [66].
• With careful patient selection, convertible total elbow arthroplasty provides patients with good to excellent outcomes and substantial improvements in the range of movements [11].
• Total elbow arthroplasty for fracture in elderly patients provides pain relief, functional range of motion, and good patient-reported outcome scores [207].
• The lateral resurfacing elbow arthroplasty 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 [20].
• Radiocapitellar prosthetic arthroplasty largely preserves elbow kinematics and stability [29].
• Management of elbow arthritis in younger and higher demand patients may benefit from a distal humerus hemiarthroplasty that employs a noncemented method of implant fixation and stabilizes the elbow through ligament reconstruction [203].
• Linking the Latitude total elbow prosthesis results in increased valgus stability [164].
• 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 [16].
• Satisfactory pain relief and good stability were obtained in all but one elbow with a very low incidence of loosening substantiating the principle of using a hingeless prosthesis for the rheumatoid elbow [105].
• None of the humeral components of the modified Liverpool total elbow prosthesis have as yet required revision [173].
• In the non-weight-bearing elbow, total joint replacement or use of acrylic cement may not be necessary [184].

Surgical Approaches and Techniques¶

• Management of the triceps is guided by the underlying pathology, implant type, and surgeon preference [103].
• The main types of approach used in TEA are triceps-splitting, -reflecting, and -sparing [103].
• 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 [103].
• The latter triceps-splitting approach allows for lengthening of the extensor mechanism in cases of extension contracture [103].
• Traditionally, the triceps-reflecting (ie, Bryan-Morrey) approach has been used for elbow replacement [103].
• In the Bryan-Morrey approach, the triceps is reflected from medial to lateral in continuity with the anconeus muscle [103].
• At the conclusion of the surgery in the Bryan-Morrey approach, the triceps is reattached to the ulna through cruciate tunnels using nonabsorbable suture passed through the triceps tendon [103].
• An additional horizontal tunnel allows passage of suture to cinch the triceps securely to the olecranon to prevent synovial fluid extravasation behind the repair [103].
• 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 [103].
• A triceps-sparing approach has been advocated for TEA to manage acute fracture of the distal humerus [103].
• Removal of the distal fracture fragments helps to maintain the triceps and achieve adequate exposure for component implantation in a triceps-sparing approach for acute fracture [103].
• A triceps-sparing approach can also be used for TEA when the distal humerus remains intact, although it is more difficult to gain the necessary exposure for component insertion [103].
• The author's experience indicates that the triceps split technique is now his preferred method for most total elbow arthroplasty cases [1].
• The triceps split approach allows total elbow arthroplasty to be performed without compromise to the triceps insertion and ideal placement of the ulnar component [33].
• The review discusses various approaches to total elbow arthroplasty and their reported outcomes to assist surgeons in making an informed choice [3].
• 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 [35].
• The modified posterior approach offers excellent exposure of the elbow joint, allows a solid repair of the triceps mechanism, and enables early mobilization after total elbow arthroplasty [68].
• The osteo-anconeus posterior approach is advocated for total elbow arthroplasty because it provides rapid and wide exposure, is associated with a low rate of complications related to the wound, and preserves the strength of the triceps [140].
• 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 [133].
• In the Mayo experience of 900 elbow replacements, 25 reoperations were performed for triceps insufficiency after the Bryan-Morrey surgical technique [137].
• The two disadvantages of olecranon osteotomy are the (low) risk of nonunion and the fact that the anconeus must be transected and denervated in order to reflect the olecranon and the extensor mechanism proximally [96].
• This causes atrophy of the anconeus and it is no longer available for some of the other reconstructive options [96].
• Olecranon osteotomy is attractive in its simplicity and remains one of the most popular exposures to the elbow worldwide, particularly for the purpose of managing fractures [96].
• The “global” approach allows circumferential exposure of the elbow [58].
• The collateral ligaments, coronoid process, and anterior joint capsule can be reached through the global approach [58].
• To extend the global approach medially, release the flexor carpi ulnaris and flexor digitorum profundus muscles subperiosteally from their ulnar origins [58].
• Retract anteriorly to expose the coron

Complications¶

Overall Complication and Revision Rates¶

• An overall complication rate in total elbow arthroplasty of up to 43% has been reported, including an 18% revision rate and 15% “permanent” complications [42].
• A recent meta-analysis reported a 13.5% revision rate for total elbow arthroplasty [42].
• Complications occurred in 21% of patients undergoing total elbow arthroplasty and lead to a decrease in satisfaction and Oxford Elbow Score after 3 years [48].
• 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 [24].
• The Latitude prosthesis provides patients with favorable clinical outcomes with a complication rate comparable to other elbow arthroplasty implants [66].
• Complication rates for elbow arthroplasty in rheumatoid arthritis have been reported from 14% to 80% with a median of 33% [117].
• A complication rate of 24% was observed in a two-centre study of the Kudo type 5 elbow prosthesis in patients with rheumatoid arthritis [117].
• An unusually high rate of complications and revisions was observed in short-term outcomes of the Nexel total elbow arthroplasty, mainly at the humeral component [125].
• A high rate of complications and revisions was observed in semiconstrained total elbow arthroplasty performed for arthritis in patients under 55 years old [251].
• High rates of early mechanical failure, predominately ulnar loosening, were observed in total elbow arthroplasty in patients aged less than 50 years [227].
• The high rate of component loosening in total elbow arthroplasty following failed internal fixation may be related to the increased pathology and technical difficulty of the procedure [218].
• A systematic review established that total elbow arthroplasty offers patients satisfactory clinical outcomes at long-term follow-up, with relatively stable revision and complication rates compared to short and medium term [243].

Infection¶

• Total elbow arthroplasty carries a higher risk of infection when compared to other major joint replacements [22].
• The reported incidence of infection in total elbow arthroplasty is 0% to 11.5% with an average of 5% to 6% [42].
• Persistent wound drainage is highly indicative of deep infection and predicts the likelihood of subsequent component resection [42].
• Two-stage revision is generally recommended for infected total elbow arthroplasty, with reports indicating an acceptable level of eradication [42].
• Well-fixed components may be retained at the time of initial debridement and placement of local antibiotics for infected total elbow arthroplasty [42].
• After completion of a course of intravenous antibiotics, a repeat debridement with re-articulation of the components can be successful for infected total elbow arthroplasty [42].
• Two-stage revision was the most effective treatment for elbow periprosthetic joint infection, showing the lowest recurrence rate for infection [245].
• The diagnosis of periprosthetic joint infection is established as definite in the presence of either a draining fistula or two or more positive cultures for phenotypically identical microorganisms [74].
• Periprosthetic joint infection is typically classified as acute (within four weeks of the procedure), chronic (infection present for more than a month), and late haematogenous (acute onset of infection in a previously uninfected total elbow arthroplasty) [74].
• Unexpected loosening of components with a reportedly good history for fixation should raise the suspicion for infection [74].
• The reduction in periprosthetic joint infection seen in a cohort treated with vancomycin powder has changed the practice of the authors, who now routinely administer vancomycin powder for total elbow arthroplasty [231].
• Surgical helmet systems do not reduce the incidence of periprosthetic joint infections in elbow arthroplasty based on results from the New Zealand National Joint Registry [239].
• Arthrodesis is not recommended as a salvage procedure for failed total elbow arthroplasty with deep infection because of the difficulty in achieving solid fusion and an increased complication rate [247].
• The most common complications found in total elbow arthroplasty allograft–prosthesis composite reconstructions were loosening and infections [128].

Mechanical Failure and Loosening¶

• Aseptic loosening, infection, and periprosthetic fracture are the most common indications for reoperation after total elbow arthroplasty [42].
• A principal complication of unconstrained total elbow arthroplasty has been loosening, usually of the humeral component [42].
• Loosening of the humeral component in semiconstrained prostheses has been reduced with improvements in prosthesis design, changes in operative technique, and better understanding of the anatomy and function of the elbow [42].
• Use of a shorter (4 inch) stem in semiconstrained total elbow arthroplasty resulted in earlier time to revision than longer (6 inch) stems [42].
• Humeral stem loosening remained uncommon at a rate of approximately 2% at an average of 7 years of follow-up [42].
• Ulnar component loosening and osteolysis increased with the addition of a polymethylmethacrylate precoat in the 1990s but has decreased since the surface finish was changed to a plasma spray preparation [42].
• Instability in the form of dislocation or subluxation is the most common complication requiring revision of unconstrained prostheses and has been reported to occur in between 9% and 10% of total elbow arthroplasties [42].
• True dislocation occurs in fewer than 5% of unlinked implants and is dependent on surgical technique [42].
• Appropriate tensioning of the medial and lateral ligament complexes and preservation of the anterior capsule and triceps can help avoid dislocation in unlinked implants [42].
• Pin disassembly of the Coonrad-Morrey total elbow replacement remains a risk despite the redesign of the locking mechanism [52].
• The risk of pin failure in Coonrad-Morrey total elbow arthroplasty appears to be greatest in younger male patients undergoing a total elbow replacement for a distal humeral fracture or post-traumatic arthritis [52].
• Periprosthetic ulnar fractures around the stem of a loose ulnar component after total elbow arthroplasty usually combine implant loosening and severe bone loss [86].
• A 20.9% revision rate was observed at a mean of 98.5 months of follow-up in a mid- to long-term survivorship study of the cemented, semiconstrained Discovery total elbow arthroplasty [77].
• Evidence of radiolucent lines was found in 59.5% of cases in a mid- to long-term survivorship study of the cemented, semiconstrained Discovery total elbow arthroplasty [77].
• Progressive humeral radiolucent lines were revealed in 14% of elbows in a study of Coonrad-Morrey total elbow arthroplasty in young patients with post-traumatic sequelae [63].
• Low-grade humeral radiolucency was detected in 31% of elbows in a study of Coonrad-Morrey total elbow arthroplasty in young patients with post-traumatic sequelae [63].
• Nonprogressive ulnar radiolucent lines were detected in 12% of elbows in a study of Coonrad-Morrey total elbow arthroplasty in young patients with post-traumatic sequelae [63].
• The ulnar component is more commonly affected by aseptic loosening and malalignment (tilting) in the Kudo type 5 elbow prosthesis [117].
• In a study of linked semiconstrained and unlinked total elbow replacement in juvenile idiopathic arthritis, 8 of 21 total elbow replacements (38.1%) were revised with exchange implants [123].
• The estimated 10-year survival was 68% in a study of linked semiconstrained and unlinked total elbow replacement in juvenile idiopathic arthritis [123].
• Revision surgery with implant revision after primary total elbow arthroplasty is common [232].
• We found acceptable implant survival rates after 5 and 10 years, with a higher revision rate for the unlinked design and primary total elbow arthroplasty due to fracture sequelae [226].

Wear and Osteolysis¶

• Wear of the polyethylene bearing surface has been reported after total elbow arthroplasty but accounts for a minority of revision procedures [42].
• Factors associated with the development of bushing wear include younger patient age, male sex, posttraumatic arthritis, preoperative elbow deformity, supracondylar nonunion, and high activity levels [42].
• Implant malalignment has been implicated in a biomechanical model regarding the development of bushing wear [42].
• 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 [42].
• Osteolytic reaction similar to that seen in total hip and knee replacements has been found in total elbow replacement [42].
• 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 [42].
• Polyethylene particles, cement, and metal debris were all found at the time of total elbow revision in another study [42].
• Osteolysis in total elbow arthroplasty is a multifactorial process [42].

Nerve and Soft Tissue Complications¶

• The most commonly encountered complications in total elbow arthroplasty include ulnar neuritis and triceps insufficiency [42].
• A 3% incidence of significant ulnar nerve complications after total elbow arthroplasty compares favorably with systematic reviews [28].
• Nerve paresthesias occur in an average of 11% of total elbow arthroplasty cases, rarely requiring surgery [42].
• Nerve entrapment occurs in an average of 3% of total elbow arthroplasty cases, usually requiring surgery [42].
• Triceps problems occur in an average of 4% of total elbow arthroplasty cases, usually requiring surgery [42].
• Wound problems occur in an average of 14% of total elbow arthroplasty cases, rarely requiring surgery [42].
• The overall incidence of soft tissue wound complication was 5.5% in a study of 97 patients undergoing total elbow arthroplasty [64].
• 81% of patients in a study of early postoperative wound complications after total elbow arthroplasty had a history of elbow surgery in the affected limb [64].
• Transient neuropathy of ulnar nerve and posterior interosseous nerve were the most commonly reported neurological complications in radial head arthroplasty, occurring in 4.73% of cases [169].
• In the majority of cases of transient neuropathy after radial head arthroplasty, the symptoms resolved spontaneously with no residual disability [169].
• Transposition of the ulnar nerve was required in only two reported cases out of 391 radial head arthroplasty cases [169].
• Superficial wound infections were reported in 0.77% of radial head arthroplasty cases and resolved completely with oral antibiotics [169].
• Deep postoperative infection was reported in one case of EVOLVE prosthesis radial head arthroplasty, which was removed as a result of an associated elbow contracture [169].
• Implant removal was required in 3.06% of radial head arthroplasty cases [169].
• Eight out of 391 radial head arthroplasty cases required revision surgeries [169].
• The most common complications in radial head arthroplasty without cement for unreconstructible radial head fractures were painful implant loosening (29.2% of 48 complications) and subluxation/dislocation of the prosthesis (18.8%) [65].
• One or more complications were observed in 30.9% of elbows undergoing radial head arthroplasty without cement for unreconstructible radial head fractures [65].
• The most common revision procedure for radial head arthroplasty without cement was implant removal (38.5% of 39 revisions), followed by arthrolysis (30.8%) [65].
• Most revision surgeries for radial head arthroplasty without cement (60.7%) occurred within the first 2 years after surgery [65].
• Longer-term studies will be required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening [108].

Fractures and Other Complications¶

• Fracture of the humerus occurs in an average of 5% of total elbow arthroplasty cases, rarely requiring surgery [42].
• Fracture of the ulna occurs in an average of 5% of total elbow arthroplasty cases, rarely requiring surgery [42].
• Ankylosis occurs in an average of 4% of total elbow arthroplasty cases, usually requiring surgery [42].
• Fracture and loosening occurs in an average of 5% of total elbow arthroplasty cases, usually requiring revision [42].
• Perioperative mortality has been reported to be 0.6% and is most commonly caused by cardiac complications [42].
• Patients with rheumatoid arthritis have higher infection rates than those with posttraumatic sequelae [42].
• Total elbow arthroplasty performed for posttraumatic arthritis is more likely to require reoperation [42].
• Arthrofibrosis is a well-described complication after total knee arthroplasty and has been described after total elbow arthroplasty [43].
• There is a lack of good quality evidence regarding the risks and benefits of venous thromboembolism prophylaxis in upper limb major joint replacement surgery [206].
• The postoperative clinical outcome after revision surgery for failed primary Souter-Strathclyde total elbow prosthesis can approximate the outcome after primary elbow replacement [49].
• 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 [50].
• In the absence of infection and instability, revision elbow arthroplasty, even in the situation of major bone loss, can be a successful treatment option using an unlinked cemented long-stem system [101].
• Revision arthroplasty in patients with bleeding disorders yields good clinical outcomes at medium-term follow-up [228].
• The results and complications of total elbow arthroplasty vary substantially depending on the indication for the procedure, the average age of the patient, the level of functional demand, the type of outcome measure used, the duration of follow-up, and surgeon experience [126].
• Satisfaction rates following total elbow arthroplasty for nonunion have ranged from 57% to 86%, and rates of complications, including infection, aseptic loosening, and ulnar neuropathy, have ranged from 18% to 48% [126].
• The complication rate for arthroscopic ulnohumeral arthroplasty of the elbow is 20%, which is comparable to those reported in a series of open ulnohumeral arthroplasties [244].
• The non-infection related adverse event rate for one-stage revision of infected elbow prostheses was 16.7% [185].
• The non-infection related adverse event rate for two-stage revision of infected elbow prostheses ranged from 11.8% to 20.0% [185].
• Non-infection related adverse events following revision surgery for infected elbow prostheses included explantation, revision, triceps weakness, insufficiency, or rupture, ulnar fracture, ulnar nerve neuropraxia, skin breakdown, humeral component loosening, and non-union [185].
• None of the six studies reporting on mortality outcomes for one- and two-stage surgical revision of infected elbow prostheses reported any mortality event associated with the revision strategy [185].
• The most common complications in total elbow arthroplasty allograft–prosthesis composite reconstructions were loosening and infections [128].
• Union was achieved in 60% of the humeral and 84% of the ulnar reconstructions in total elbow arthroplasty allograft–prosthesis composite reconstructions [128].

Recovery¶

• Early mobilization can be pursued to overcome many of the pitfalls involved in rehabilitation of the elbow [51].
• The modified posterior approach for total elbow replacement enables early mobilization after total elbow arthroplasty [68].
• Ninety-four percent of patients engaged in moderate-demand activities after total elbow arthroplasty [152].
• Forty percent of patients engaged in high-demand activities after total elbow arthroplasty [152].
• Functional improvement by means of total elbow replacement is possible when proper indications are satisfied, including patient understanding of risks and ability to comply with postoperative rehabilitation [39].

Key Evidence¶

• [L4] The author's experience indicates it is now his preferred method for most total elbow arthroplasty cases. [1] (10.1097/00132589-200203000-00006)
• [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)
• [L4] The review discusses various approaches to total elbow arthroplasty and their reported outcomes to assist surgeons in making an informed choice. [3] (10.1177/1758573216682479)
• [L3] In most cases, elbow function was maintained in the long-term without loosening of the implant. [4] (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. [5] (10.1016/j.jhsa.2016.07.007)
• [L4] Surveillance efficacy is higher in primary linked total elbow arthroplasty than primary shoulder arthroplasty, supporting appropriate resource allocation for elbow arthroplasty surveillance. [6] (10.1177/17585732241301356)
• [L5] The continued success of total elbow arthroplasty will depend on advances in surgical planning, technique, implant design, and materials. [7] (10.5435/jaaos-d-25-00473)
• [L3] Obese patients being considered for elbow replacement surgery should be counseled accordingly. [10] (10.2106/jbjs.m.00364)
• [L4] With careful patient selection, convertible total elbow arthroplasty provides patients with good to excellent outcomes and substantial improvements in the range of movements. [11] (10.1177/1758573221991511)
• [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. [13] (10.1016/j.jhsa.2013.03.051)
• [L4] Elbow hemiarthroplasty is an option for young or active patients with end-stage posttraumatic arthritis who are unwilling to accept activity limitations, though high rates of revision surgery and revision to total elbow arthroplasty occur. [14] (10.5435/jaaos-d-18-00055)
• [L4] This approach represents an alternative to the use of hemi or total elbow replacement in younger patients who have undergone multiple prior surgeries. [15] (10.1016/j.jseint.2024.06.002)
• [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. [16] (10.1302/2058-5241.2.160064)
• [L2] The range of indications for total elbow arthroplasty is broadening; total elbow arthroplasty for acute trauma and osteoarthritis is becoming increasingly more common. [18] (10.1302/2058-5241.5.190036)
• [L4] The complication and revision rates are comparable to other indications for elbow replacement surgery. [19] (10.1177/17585732211014832)
• [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. [20] (10.1302/0301-620x.100b3.bjj-2017-0865.r1)
• [L4] Total elbow arthroplasty carries a higher risk of infection when compared to other major joint replacements. [22] (10.1177/1758573218789341)
• [L4] Survival rates nonetheless remain low and complication rates remain high yet are comparable to those of other elbow arthroplasties. [24] (10.1016/j.jse.2021.08.028)
• [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. [25] (10.1016/j.jhsg.2023.05.006)
• [L4] Most of the literature dealing with elbow arthroplasty consists of retrospective observational studies with small sample sizes and short follow-up. [26] (10.1302/0301-620x.104b10.bjj-2022-0570.r1)
• [L4] A 3% incidence of significant ulnar nerve complications after total elbow arthroplasty compares favorably with systematic reviews. [28] (10.1016/j.jhsa.2015.06.107)
• [L4] The procedure largely preserves elbow kinematics and stability. [29] (10.1016/j.jse.2014.01.042)
• [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] Our approach allows total elbow arthroplasty to be performed without compromise to the triceps insertion and ideal placement of the ulnar component. [33] (10.1097/bte.0000000000000166)
• [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. [35] (10.1016/j.jse.2021.09.005)
• [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. [39] (10.2106/00004623-198971040-00006)
• [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. [43] (10.1016/j.jse.2013.10.009)
• [Abstract] Total elbow arthroplasty is a durable and effective option in alleviating pain and restoring motion in the salvage elbow. [46] (10.1016/j.jse.2007.02.071)
• [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. [48] (10.1016/j.jseint.2021.02.015)
• [L4] The postoperative clinical outcome after revision surgery can approximate the outcome after primary elbow replacement. [49] (10.1016/j.jse.2005.07.009)
• [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. [50] (10.1016/j.jse.2020.08.018)
• [L5] Many of the pitfalls involved in rehabilitation of the elbow can be overcome if early mobilization can be pursued. [51] (10.1016/s0894-1130(99)80003-9)
• [L4] [52] (10.1111/j.1758-5740.2012.00191.x)
• [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. [56] (10.1016/j.jhsg.2023.08.002)
• [L4] [63] (10.1016/j.jse.2022.03.021)
• [L4] [64] (10.1016/j.jse.2011.03.005)
• [L4] [65] (10.2106/jbjs.20.01231)
• [L4] The Latitude prosthesis provides patients with favorable clinical outcomes with improvements in their range-of-motion and a complication rate comparable to other elbow arthroplasty implants. [66] (10.1177/1758573218768510)
• [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. [68] (10.1177/1758573214559319)
• [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. [69] (10.1016/j.jhsa.2018.11.005)
• [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. [71] (10.1016/j.jse.2025.05.024)
• [L5] [74] (10.1302/0301-620x.106b11.bjj-2024-0549.r1)
• [L4] [77] (10.1016/j.jse.2020.12.007)
• [L4] Treatment options range from conservative management to open debridement, arthroscopy, and total elbow arthroplasty in selected patients. [84] (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. [86] (10.2106/jbjs.j.00102)
• [L4] Elbow hemiarthroplasty is a viable option for complex distal humeral fractures in select patients, offering functional outcomes comparable to total elbow arthroplasty while potentially avoiding complications related to the ulnar component. [88] (10.1177/1758573216640210)
• [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. [91] (10.1016/j.jse.2015.11.048)
• [L4] In addition, valgus stress on the elbow joint may have contributed to these implant failures. [94] (10.1016/j.jse.2018.05.002)
• [L5] [96] (10.1097/00132589-200203000-00003)
• [L4] The results show that in the absence of infection and instability, revision elbow arthroplasty, even in the situation of major bone loss, can be a successful treatment option using this unlinked cemented long-stem system. [101] (10.1053/jhsu.1999.1337)
• [L4] [103] (10.5435/jaaos-21-07-427)
• [L4] Satisfactory pain relief and good stability were obtained in all but one elbow, with a very low incidence of loosening substantiating the principle of using this type of hingeless prosthesis. [105] (10.2106/00004623-198062020-00015)
• [L4] [106] (10.1016/s0363-5023(09)60123-4)
• [L3] [107] (10.1016/j.jse.2024.03.032)
• [L3] Longer-term studies will be required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening. [108] (10.1007/s11999-013-3331-x)
• [L5] This study analyzed elbow joint moments in different directions during daily tasks. [110] (10.1016/j.jse.2023.07.042)
• [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. [113] (10.1302/0301-620x.106b10.bjj-2024-0405.r1)
• [L3] [117] (10.1111/j.1758-5740.2009.00011.x)
• [L3] [123] (10.1016/j.jse.2016.06.011)
• [L4] However, an unusually high rate of complications and revisions was observed, mainly at the humeral component. [125] (10.1016/j.jse.2021.02.009)
• [L5] [126] (10.2106/jbjs.j.00777)
• [L4] [128] (10.5397/cise.2025.01067)
• [L5] Shoulder abduction results in a varus moment at the elbow. [129] (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. [132] (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. [133] (10.1016/j.jseint.2024.12.003)
• [L5] In the Mayo experience of 900 elbow replacements, 25 reoperations were performed for triceps insufficiency after the surgical technique described above. [137] (10.1097/00132589-200203000-00007)
• [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. [138] (10.2106/00004623-198971070-00013)
• [L5] Cementing a nonanatomic hinge that may not rely on the native elbow soft tissue support can result in a troubling biomechanical environment. [139] (10.1016/j.jhsa.2018.11.020)
• [L4] The osteo-anconeus posterior approach is advocated for total elbow arthroplasty because it provides rapid and wide exposure, is associated with a low rate of complications related to the wound, and preserves the strength of the triceps. [140] (10.2106/00004623-199072050-00007)
• [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. [145] (10.1302/0301-620x.95b10.31844)
• [L4] Ninety-four percent of patients engaged in moderate-demand activities after total elbow arthroplasty, and forty percent engaged in high-demand activities. [152] (10.1016/j.jse.2013.01.023)
• [L5] Overstuffing the radial head prosthesis alters joint kinematics and may lead to pain and degenerative changes. [153] (10.1177/1758573219881772)
• [L4] The valgus angulation of the available elbow designs is discordant with the mean native valgus angulation found in this study, and the valgus laxity of the implants does not cover the variability in the studied population. [154] (10.1016/j.jse.2023.04.017)
• [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. [160] (10.1016/j.jseint.2024.10.017)
• [L5] The plane through the ridge of the GSN of a healthy proximal ulna could provide a more reliable anatomical landmark to estimate the position of the elbow FE axis compared to the posterior surface (95% CI range: 11°). [161] (10.1016/j.jseint.2024.10.016)
• [L5] The radial head prosthesis mimics the mechanics of the native radial head in terms of mean contact area, mean contact pressure, and peak contact pressure; however, different patterns of contact pressure and area curves during elbow flexion-extension were observed. [163] (10.1016/j.jhsa.2018.08.005)
• [L5] Linking the Latitude total elbow prosthesis results in increased valgus stability. [164] (10.1016/j.jse.2013.02.010)
• [L5] This study demonstrates that the posterior flange withstood static and dynamic forces greater than what is expected during in vivo use of a novel total elbow arthroplasty design. [165] (10.1016/j.jhsg.2022.12.008)
• [L4] Elbow arthroplasty using a cemented linked semiconstrained implant provides satisfactory clinical results in the treatment of rheumatoid arthritis with a reasonable rate of survivorship free of mechanical failure at 20 years. [168] (10.2106/jbjs.15.00649)
• [L4] [169] (10.1177/1758573214524934)
• [Case_report] Total elbow replacement restored the bone defect and offered an excellent functional outcome in combination with attachment tube soft tissue reconstruction. [172] (10.1016/j.jseint.2023.01.007)
• [L4] None of the humeral components of the modified prosthesis have as yet required revision. [173] (10.1016/0266-7681(94)90173-2)
• [L5] This complication can be minimized by placing the elbow in deep flexion during surgery and removing any impinging anterior structures. [176] (10.1016/j.jhsg.2020.07.004)
• [L1] [185] (10.1186/s12891-019-2848-x)
• [L5] An MUCL insufficient elbow experiences an increase in valgus angle and a propensity for the ulna to go into internal rotation under valgus stress. [186] (10.1016/j.jse.2016.12.043)
• [L5] The measured landmarks show no consistent rotational relationship with the maximum diameter of the radial head. [188] (10.1016/j.jse.2013.02.013)
• [L4] Anatomical variations at the distal humerus and proximal ulna affect the alignment of the components at TEA. [189] (10.1302/0301-620x.97b11.36071)
• [L2] Osteocapsular debridement is an effective surgical treatment option for patients with symptomatic primary elbow osteoarthritis who have failed conservative management. [199] (10.1016/j.jse.2020.01.060)
• [L5] Management of elbow arthritis in younger and higher demand patients may benefit from a distal humerus hemiarthroplasty that employs a noncemented method of implant fixation and stabilizes the elbow through ligament reconstruction. [203] (10.1016/j.jhsg.2023.07.003)
• [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. [206] (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. [207] (10.1016/j.jhsa.2020.10.034)
• [L5] [208] (10.1016/j.jhsa.2024.09.006)
• [L5] [209] (10.1016/j.jse.2011.05.024)
• [L4] [216] (10.1016/j.jse.2021.12.005)
• [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. [218] (10.1016/j.jse.2007.02.051)
• [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. [226] (10.1016/j.jse.2014.02.001)
• [L4] High rates of early mechanical failure, predominately ulnar loosening, were observed in TEA in patients aged less than 50 years. [227] (10.1016/j.jhsa.2017.06.101)
• [L4] Revision arthroplasty in this group of patients yields good clinical outcomes at medium-term follow-up. [228] (10.1016/j.jse.2015.01.004)
• [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. [231] (10.1016/j.xrrt.2025.06.013)
• [L4] Revision surgery with implant revision after primary TEA is common. [232] (10.1016/j.jse.2016.12.064)
• [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. [239] (10.1016/j.jse.2024.11.034)
• [L4] Our systematic review established that TEA offers patients satisfactory clinical outcomes at long-term follow-up, with relatively stable revision and complication rates compared to short and medium term. [243] (10.1016/j.jse.2020.11.014)
• [L4] The complication rate although high (20%) is comparable to those reported in a series of open ulnohumeral arthroplasties. [244] (10.1016/s1058-2746(96)80505-2)
• [L4] Two-stage revision was the most effective treatment for elbow PJI, showing the lowest recurrence rate for infection. [245] (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. [247] (10.1016/j.jse.2013.11.007)
• [L4] However, a high rate of complications and revisions was observed with follow-up. [251] (10.1016/j.jse.2019.08.006)

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