Updated: 9/12/2022

Total Elbow Arthroplasty

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  • summary
    • Total Elbow Arthroplasty (TEA) is an increasingly used motion-preserving modality for the treatment of many debilitating elbow pathologies.
    • Primary indications include rheumatoid arthritis, post-traumatic arthritis, and intra-articular distal humeral fractures in the elderly with poor bony quality.
    • Semiconstrained implants have the best longevity and most optimal functional outcomes.
  • Epidemiology 
    • TEA for trauma is one of the fastest-growing indications
  • Etiology
    • Forms of elbow arthroplasty
      • total elbow arthroplasty
      • hemi elbow arthroplasty
        • radiocapitellar
        • distal humeral
      • ulnohumeral distraction & interpositional arthroplasty
      • olecranon fossa debridement
      • radial head arthroplasty
  • Indications
    • Indications
      • rheumatoid arthritis (RA)
        • indication
          • 10-20% of patients with RA will have arthritic changes in the elbow
            • TEA considered for Larsen stages 3 to 5 with:
              • functional loss
              • pain
              • instability
          • ideally, patient should be older than 65 years old
        • outcomes
          • longest survivorship when TEA is performed for RA compared to other indications
            • most reliable with advanced, refractory RA
      • primary osteoarthritis (advanced)
        • indication
          • patient should be older than 65 years old
          • mid-arc pain with activity resulting from ulnotrochlear joint cartilage loss
        • outcomes
          • 10-year implant survival about 80-85% for TEA for primary OA
      • fracture
        • indication
          • physiologically elderly patient (e.g., > 70 years) with:
            • acute complex, unreconstructable intra-articular distal humerus fracture
            • missed elbow fracture dislocation
            • poor quality bone
        • outcomes
          • faster recovery with more predictable functional outcomes compared to fixation strategies
          • limitations of lifting weight more than 5 to 10 pounds to avoid implant loosening
      • posttraumatic osteoarthritis (advanced)
      • chronic instability
    • Contraindications
      • absolute
        • active infection (arthrodesis favored)
        • Charcot joint
      • relative
        • poor neurologic control of affected extremity
        • active patient younger than <65 years old
        • olecranon osteotomy
  • Implants
    • Designs
      • unconstrained or unlinked components
        • example
          • Ewald capitello-condylar design
        • technical aspects
          • requires competent collateral ligaments and soft tissue envelope
          • requires good bone quality
        • outcomes
          • instability is most common complication (5-10% dislocation)
          • precise component alignment is required
          • no proven superiority or clear indication compared with semiconstrained/linked
      • semiconstrained or linked components
        • examples
          • Coonrad-Moorey design
        • technical aspects
          • "sloppy hinge" allows for some varus-valgus and rotational laxity
          • reduces stress on bone-cement interface, which reduces incidence of component loosening
        • outcomes
          • best results of all the designs
          • complication of early humeral loosening with designs without an anterior flange
      • constrained
        • example
          • Dee design
        • technical aspects
          • rigid hinged design
          • theoretically most stable design (versus unlinked)
        • outcomes
          • highest loosening rates compared to semiconstrained and unconstrained designs
    • Design pearls
      • component stems (ulna and humerus) have improved fixation and reduced loosening
      • humeral component extracortical anterior flange resists posteriorly directed and rotational forces
      • radial head not needed for stability in linked TEA designs
        • radial head often debrided or resected in RA, due to mechanical symptoms or pain
  • Key Technical Concepts
    • Preoperative care
      • clinical evaluation
        • age > 65
        • low demand patient
        • able to comply with post-operative weight-bearing restriction (none do so be careful who you operate on)
        • medical optimization
      • imaging
        • standard radiographs
          • AP and lateral views of elbow
            • assess bone stock
            • ensure medial and lateral columns are intact
            • assess canal diameter for implant design
          • cervical spine
            • flexion-extension views
              • rheumatoid arthritis patients
        • CT scan
    • Surgical
      • positioning
        • supine
          • arm draped free
          • requires an assistant to hold the arm over the patients chest
            • surgeon must take care to avoid the endotracheal tube
        • lateral decubitus
          • arm positioned over a bolster
          • minimizes the need for an assistant to hold arm
            • decreases the ability to manipulate the arm
      • approach
        • triceps-reflecting, triceps-splitting, and triceps-sparing
          • triceps-reflecting (Bryan-Morrey)
            • triceps reflected from medial to lateral in continuity with the anconeous
            • triceps re-attached to ulna with nonabsorbable suture through bone tunnels
              • There can be associated weakness or loss of elbow extension due to the detachment of the triceps brachii insertion from the olecranon.
          • triceps tongue
            • raise fascial tongue from olecranon back proximally
            • release collateral ligaments proximally and distally
            • can be used for fractures or TEA
          • triceps-splitting
            • triceps is longitudinally divided in continuity with forearm fascia over dorsal ulna
            • triceps can also be split proximally with a V-shaped turndown of the tendon, leaving insertion onto olecranon intact
              • allows for extensor mechanism lengthening if needed
          • triceps-sparing
            • triceps preserved intraoperatively, but exposure can be challenging
            • medial and lateral borders of triceps are mobilized
            • best for using TEA to manage acute distal humerus fractures
          • triceps "on"
            • direct midline, posterior incision
            • identify, release and protect the ulnar nerve
            • release the flexor-pronator mass and medial collateral ligament from medial epicondyle
            • elevate the triceps off the posterior humerus towards the lateral intermuscular septum
            • release the common extensors and lateral collateral ligament complex
            • disarticulate the ulno-humeral joint
        • technique
          • bone preparation
            • preparation of humeral component
              • resect the olecranon fossa of distal humerus
                • keep medial and lateral column intact
                • broaching to appropriate sized component
            • preparation of ulnar component
              • resect the olecranon tip of proximal ulna
              • resect tip of coronoid to avoid impingement on anterior flange which will cause axial pistoning of ulna and loosening
                • broaching to appropriate sized component
          • implant insertion
            • component design
              • semiconstrained most common
              • modern cement preparation and technique
            • humerus component
              • prepare a wedge-shaped piece of bone for placement behind the humeral flange
              • maintain component orientation relative to the posterior flat surface of the distal humerus
            • ulnar component
              • orient the implant perpendicular to the dorsal flat surface of the olecranon
    • Postoperative care
      • early period of immobilization
        • early motion after TEA is associated with wound complications, instability, and hardware loosening
        • typically immobilize for 4 weeks after surgery
      • lifelong weightlifting restriction of less than 5-10 lbs
  • Outcomes
    • Rheumatoid arthritis TEA outcomes
      • 10 year survivorship
        • 92.4% rate of survivorship free of revision at 10 years
        • however very high complication rate (14%)
          • triceps avulsion
          • deep infection
          • periprosthetic fracture
          • aseptic loosening
    • Post traumatic arthritis TEA outcomes
      • 5 year survivorship
        • most achieve functional ROM and patient satisfaction
        • high complication rate (27-43%)
        • high re-operation rate (25%)
  • Complications
    • Aseptic loosening (radiographic 17%, clinical 6%)
      • most common mode of failure for constrained
    • Infection (8%)
      • acute infection (< 30 days)
        • treatment
          • aggressive serial irrigation and debridement and antibiotic bead placement
          • success depends on organism
            • staphylococcus epidermidis is associated with persistent infection because it is an encapsulating organism, and it is best treated with implant removal and IV antibiotic
      • chronic infection
        • treatment
          • two staged reimplantation versus resection arthroplasty in medically ill patients or those with inadequate bone stock.
    • Instability (7-19%)
      • most common mode of failure for semiconstrained
    • Bushing wear (obtain AP xrays and varus/valgus angle of > 10 degrees is concerning)
      • common mode of failure for constrained
    • Wound healing (higher with longterm steroid use)
    • Ulnar neuropathy
    • Triceps insufficiency
    • Bone loss
      • from multiple revisions, fractures, osteolysis
      • graded based on humeral bone stock
      • treatment
        • up to 8cm of distal humeral loss can be replaced with longer prosthesis with extended anterior flange or endoprosthesis (total humerus)
        • salvage options include flail elbow, amputation, arthrodesis
    • Periprosthetic fracture
      • in 5-30% of primary TEAs
      • causes
        • trauma
        • osteoporosis
        • aseptic loosening
        • stress shielding
        • poor technique
        • non compliance with activity restriction
      • classification based on that for periprosthetic femoral fractures (see table below)
        • Mayo (O'Driscoll & Morrey) Classification of Periprosthetic fracture
        • Characteristics
        • Treatment
        • Type I
        • Periarticular fracture involving the humeral condyle or olecranon.
        • Caused by osteolysis around hinge components and distracting forces from muscle attachments
        • Undisplaced - Immobilization /soft tissue repair is sufficient to achieve fibrous union (Rigid fixation not required).
        • Displaced - ORIF with heavy nonabsorbable sutures or tension band wiring (if limited periprosthetic bone)
        • Type II
        • Fracture along length of humeral or ulnar stem. Subtypes:
        •   II1: well-fixed implant
        •     II2: loose implants, good bone stock
        •     II3: loose implants, severe bone loss
        • I1: ORIF with component retention +/- strut allograft
        • II2: Revision arthroplasty using long-stem prosthesis ± strut allograft and impaction bone grafting. Locking plates/ cerclage wires may be added for added stability.
        • II3: Require revision arthroplasty with extensive allograft supplementation. Often times require resection arthroplasty
        • Type III
        • Distal to prosthesis.
        • Treated like routine fractures.
        •  Radiographs/CTs to ensure implants are not loose, cement mantle not cracked.
        • If implants are well-fixed, immobilization for humerus and ORIF for ulna.
        • If implants are loose, treat as Type II2 fractures.
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(OBQ15.213) Which patient would expect to have the longest implant survivorship after undergoing total elbow arthroplasty (TEA)?

QID: 5898

Rheumatoid arthritis with unconstrained TEA



Rheumatoid arthritis with semiconstrained TEA



Primary osteoarthritis with semiconstrained TEA



Primary osteoarthritis with unconstrained TEA



Acute distal humeral bicolumnar fracture with semiconstrained TEA



L 4 B

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(OBQ14.12) A 72-year-old woman presents for follow-up after elbow surgery. Her radiographs are shown in Figures A and B. Which of the following pre-operative diagnoses is a relative contraindication to the use of this prosthesis design?

QID: 5422

Acute intra-articular distal humerus fracture



Malunited intra-articular distal humerus fracture



Late-stage rheumatoid arthritis



Post-traumatic bony ankylosis






L 4 B

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(OBQ12.40) A 62-year-old female with history of rheumatoid arthritis presents with end-stage elbow arthritis. Regarding total elbow arthroplasty (TEA) for rheumatoid arthritis, which of the following implant survival results would be expected?

QID: 4400

Poor survival results by 5 years



Good survival results at 5 years, poor results by 10 years



Good survival results at 10 years, poor results by 15 years



Good survival results at 15 years



Lack of long-term survival studies regarding TEA for rheumatoid arthritis



L 4 B

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(SAE08UE.9) A 82-year-old woman with rheumatoid arthritis falls onto her nondominant left elbow and sustains the injury shown in Figure A. What treatment option allows her the shortest recovery time and highest likelihood of good function and range of motion?

QID: 6571

Total elbow arthroplasty



Open reduction and internal fixation



Radial head arthroplasty



Sling and swathe



Bone stimulator



L 2 E

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Evidence (29)
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