Total Elbow Arthroplasty — Indications & Outcomes

Total elbow arthroplasty (TEA) is a relatively uncommon surgical procedure — performed approximately 1.4 per 100,000 people annually in the United States, compared to 70–99 per 100,000 for hip arthroplasty. Despite its relative rarity, its use has almost doubled between 1998 and 2011. TEA replaces the ulnohumeral articulation (and occasionally the radiocapitellar joint) with a prosthetic implant, providing pain relief and functional restoration in end-stage elbow disease. The elbow is a non-weight-bearing joint but can transmit static loads of up to 3× body weight and dynamic loads of 6× body weight during activities of daily living — making implant durability a significant challenge. As a consequence, TEA has higher complication rates than hip or knee arthroplasty, and outcomes are highly dependent on surgical volume and patient selection.

• Indications for TEA: (1) rheumatoid arthritis (RA) — historically the dominant indication; severe RA with Larsen grade IV–V joint destruction, failed medical management; TEA produces excellent pain relief and functional restoration in RA; note that disease-modifying anti-rheumatic drugs (DMARDs) and biologics have reduced the need for TEA in RA; (2) comminuted distal humerus fracture in the elderly — an irreparable comminuted intra-articular distal humerus fracture in a patient >65 years (low functional demand, osteoporotic bone making ORIF technically challenging with high failure rates) is now an increasing indication for primary TEA; results are best in elderly low-demand patients; (3) post-traumatic arthritis — OA secondary to prior fracture or dislocation; outcomes inferior to RA; (4) primary osteoarthritis (rare); (5) tumour resection — after resection of distal humeral or proximal ulnar tumours; (6) acute radial head fractures (hemiarthroplasty — not full TEA)
• Contraindications: active infection (absolute); young age and high functional demands (relative — the 5 kg lifting restriction after TEA is incompatible with physical labour or sport; TEA is generally avoided in patients <60 years with high activity demands); significant loss of soft tissue coverage around the elbow; non-reconstructable bone loss preventing stem fixation

• All TEA approaches use a single posterior skin incision; the key distinction is the handling of the triceps mechanism and the ulnar nerve
• Bryan-Morrey approach (triceps-reflecting): the triceps is reflected off the olecranon with a continuous cuff of tissue including the periosteum and a portion of the anconeus; this approach provides excellent distal humeral and proximal ulnar exposure; the triceps is repaired to the olecranon at closure through bone tunnels; post-operatively, active triceps use is restricted for 6 weeks to protect the triceps repair; the most widely used approach for linked TEA (Coonrad-Morrey)
• Paratricipital (Alonso-Llames) approach: medial and lateral windows are developed alongside the triceps without disturbing its insertion; the triceps is retracted rather than detached; no triceps restriction post-operatively; provides adequate access for most unconstrained designs; limited proximal ulnar exposure
• Triceps splitting approach: the triceps tendon is split longitudinally in the midline; triceps strength is generally preserved; alternative to Bryan-Morrey in some centres
• Ulnar nerve management: the ulnar nerve must be identified and protected throughout TEA surgery; it lies in the cubital tunnel posterior to the medial epicondyle; most surgeons routinely transpose the ulnar nerve anteriorly (subcutaneous anterior transposition) to protect it from stretch, retractor injury, and post-operative scar tethering at the cubital tunnel; some surgeons perform only an in situ release of the cubital tunnel retinaculum without transposition; ulnar nerve palsy is the most common nerve complication of TEA (reported in 2–10% of cases)
• Cementing: both humeral and ulnar components are cemented in the vast majority of TEA cases; the canal is prepared, irrigated, and filled with cement in retrograde fashion (cement gun); the humeral component is typically inserted first, then the ulnar component; the bushing is snap-locked into the humeral component, and the hinge pin is inserted to link the components (for linked designs); the elbow is reduced and the cement is allowed to cure before wound closure

• Infection: the most serious complication; reported in 1–12.5% of cases (range reflects patient population — RA patients on immunosuppressants have higher infection risk); TEA infection management is more challenging than hip/knee PJI because of the thin soft tissue envelope around the elbow — debridement and retention (DAIR) has a very low success rate; two-stage revision (antibiotic cement spacer + reimplantation) is preferred for early/late infections; amputation is occasionally required for refractory infection; the risk of infection is reduced by preoperative optimisation of immunosuppression (hold methotrexate and biologics perioperatively per rheumatology guidance)
• Aseptic loosening: the most common late failure mode; 5-year loosening rates 6–17% for semi-constrained designs (significantly lower than fully constrained designs); bushing wear leads to osteolysis; ulnar component more commonly involved than humeral (anterior distracting force from heterotopic bone, coronoid process, or prosthesis flange); revision with longer stems ± strut allograft is required for established loosening
• Bushing wear and polyethylene failure: the polyethylene bushing in the hinge mechanism of semi-constrained TEA wears over time (cyclic loading in flexion/extension); bushing wear produces polyethylene debris and osteolysis; modern designs have increased the size of the bushing interface (larger wheel and spool) to reduce contact stress and wear rates; the bushing can be exchanged in isolation (without revising both components) if the stems are well-fixed
• Triceps weakness: post-operative triceps weakness occurs in approximately 5–10% of TEA cases; the Bryan-Morrey approach requires careful triceps reattachment and post-operative protection; premature active use of the triceps risks avulsion of the repair; patients must be counselled that restricted elbow extension strength may limit certain activities
• Periprosthetic fracture: occurs in approximately 3–5% of TEA; the thin cortices of the distal humerus and proximal ulna are vulnerable to fracture around the prosthetic stems; intraoperative fractures from over-vigorous reaming; post-operative fractures from falls; management — stable undisplaced fractures around well-fixed stems → conservative (long arm cast or brace); displaced or stem-unstable fractures → ORIF with plate/cerclage + consider stem revision
• The 5 kg lifting restriction: a critical post-operative instruction for all TEA patients; repeated loading >5 kg accelerates bushing wear and loosening; patients must be counselled that TEA is incompatible with heavy lifting, manual labour, or high-impact upper limb sports; this restriction is permanent and is the main reason TEA is avoided in younger active patients

• RA outcomes: the best results are in RA patients; Mayo series (Coonrad-Morrey) — 97% survival at 5 years; 85% survival at 10 years; mean Mayo Elbow Performance Score (MEPS) approximately 91/100; 10-year overall TEA survival from the Danish registry approximately 81%; outcomes are best in specialist RA centres with high surgical volume (Finnish registry data — hospital volume significantly affects TEA survival)
• Distal humerus fracture TEA: outcomes in acute fracture TEA are comparable to RA TEA in elderly patients; significantly superior to ORIF in comminuted fractures in patients >65 years (lower reoperation rates, faster rehabilitation, better functional scores in RCTs); outcomes inferior to RA TEA when TEA is performed for post-traumatic OA (attenuated ligaments, distorted anatomy, higher complication rates)
• Surgeon volume effect: TEA is a low-volume procedure and outcomes are highly dependent on surgical experience; high-volume specialist centres show significantly better implant survival than low-volume hospitals (Finnish and Scottish arthroplasty register data); TEA should be concentrated in specialist upper limb centres with dedicated elbow arthroplasty expertise

• TEA indications: RA (Larsen IV–V) — best outcomes; elderly distal humerus fracture (>65 years, irreparable comminution) — increasing indication; post-traumatic OA; tumour resection; primary OA (rare)
• Constraint hierarchy: constrained (fully linked fixed hinge) — abandoned (25% loosening at 5 years); semi-constrained (sloppy hinge — Coonrad-Morrey) — current gold standard; unconstrained (Kudo, Souter-Strathclyde) — requires intact ligaments, lower loosening rate; convertible/linkable (Latitude) — intraoperative flexibility
• Coonrad-Morrey: most widely used globally; titanium or CoCr; anterior humeral flange for rotational stability; 7–10° sloppy hinge; 85% 10-year survival in RA (Mayo series); allows 6–17% loosening at 5 years semi-constrained
• Ulnar nerve: identify and protect; most surgeons perform anterior subcutaneous transposition; most common nerve complication of TEA (2–10%); failure to protect → ulnar nerve palsy → intrinsic hand weakness + ring/little finger sensory loss
• Bryan-Morrey approach: triceps reflected off olecranon with continuous cuff; best distal humeral exposure; repair through bone tunnels at closure; 6-week triceps protection post-op; most widely used for Coonrad-Morrey TEA
• 5 kg permanent lifting restriction: mandatory post-TEA; repeated loading >5 kg accelerates bushing wear and loosening; incompatible with manual labour or high-impact sport; main reason TEA avoided in young active patients
• Infection: 1–12.5%; DAIR rarely successful (thin soft tissue envelope); two-stage revision preferred; RA patients on immunosuppressants at higher risk; hold methotrexate/biologics perioperatively
• Bushing wear: polyethylene bushing in sloppy hinge → wear debris → osteolysis; ulnar component more commonly loose; modern designs — larger bushing interface; bushing exchange possible without full stem revision if stems well-fixed
• TEA for distal humerus fracture: >65 years, irreparable comminution; superior to ORIF in RCTs in elderly patients; immediate stability; faster rehabilitation; outcomes inferior when performed for established post-traumatic OA
• Surgeon volume: TEA outcomes highly volume-dependent; specialist centres → significantly better survival; TEA should not be performed by low-volume surgeons