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 login to view 6 more bullets outcomes login to view 2 more bullets primary osteoarthritis (advanced) indication login to view 2 more bullets outcomes login to view 1 more bullet fracture indication login to view 4 more bullets outcomes login to view 2 more bullets 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 login to view 1 more bullet technical aspects login to view 2 more bullets outcomes login to view 3 more bullets semiconstrained or linked components examples login to view 1 more bullet technical aspects login to view 2 more bullets outcomes login to view 2 more bullets constrained example login to view 1 more bullet technical aspects login to view 2 more bullets outcomes login to view 1 more bullet 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 login to view 7 more bullets CT scan Surgical positioning supine login to view 3 more bullets lateral decubitus login to view 3 more bullets approach triceps-reflecting, triceps-splitting, and triceps-sparing login to view 24 more bullets technique login to view 18 more bullets Postoperative care early period of immobilization early motion after TEA is classically associated with wound complications, instability, and hardware loosening newer evidence supports a variety of post-operative immobilization protocols login to view 2 more bullets 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%) login to view 4 more bullets 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 login to view 3 more bullets chronic infection treatment login to view 1 more bullet 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.