The Open Orthopaedics Journal, 2011, 5, 115-123 115

Open Access
Total Elbow Arthroplasty
Joaquin Sanchez-Sotelo*

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA

Abstract: Total elbow arthroplasty has continued to evolve over time. Elbow implants may be linked or unlinked.
Unlinked implants are attractive for patients with relatively well preserved bone stock and ligaments, but many favor
linked implants, since they prevent instability and allow replacement for a wider spectrum of indications. Inflammatory
arthropathies such as rheumatoid arthritis represent the classic indication for elbow arthroplasty. Indications have been
expanded to include posttraumatic osteoarthritis, acute distal humerus fractures, distal humerus nonunions and
reconstruction after tumor resection. Elbow arthroplasty is very successful in terms of pain relief, motion and function.
However, its complication rate remains higher than arthroplasty of other joints. The overall success rate is best for patients
with inflammatory arthritis and elderly patients with acute distal humerus fractures, worse for patients with posttraumatic
osteoarthritis. The most common complications of elbow arthroplasty include infection, loosening, wear, triceps weakness
and ulnar neuropathy. When revision surgery becomes necessary, bone augmentation techniques provide a reasonable
outcome.
Keywords: Arthroplasty, elbow, rheumatoid arthritis, elbow fractures, osteoarthritis.

Replacement arthroplasty of the elbow is in constant components (Table 1). A common misconception is to
evolution. Although it was initially used mainly in patients equate linking to constraint: some unlinked implants are
with inflammatory arthritis, its indications were expanded to more constrained than their linked counterparts.
other conditions, which place higher demands on the Table 1. Main Implants Available for Replacement of the
implants and seem to lead to higher failure rates [1]. Elbow Elbow Joint
arthroplasty presents some unique peculiarities. Compared to
the hip and knee joints, the elbow is relatively small and its
stability depends greatly on ligamentous integrity. Linked Linked Unlinked Linkable
semiconstrained elbow arthroplasties became popular in the
Coonrad-Morrey Capitellocondylar Acclaim
United States and central Europe; these inherently stable
implants raise the concern of increased contact pressures on Discovery iBP Latitude
the already thin polyethylene. Unlinked arthroplasties, GSB III Kudo
popular in the United Kingdom and Asia, may have better Norway Norway
tribological properties but are at risk for instability and Pritchard Mark II Pritchard II (ERS)
decreased elbow extension. Pritchard-Walker Sorbie
Elbow arthroplasty is further complicated by the need to Souter-Strathclyde
violate the extensor mechanism for exposure, the increased
risk of infection, the role of the radial head, and potential
Linked/Coupled Implants
clinical problems related to the ulnar nerve. Present and
future innovations may include the use of linkable implants, The distinguishing feature of this category of implant is
alternative bearing surfaces, uncemented fixation, distal the physical linking of the humeral and ulnar components at
humerus hemiarthroplasties, unicompartimental arthro- the time of surgery in order to avoid subluxation or
plasties, implantation with the aid of computerized dislocation episodes. Early linked implants were constrained
navigation systems, and improved revision systems. hinges that only allowed flexion and extension. These
implants were associated with a high failure rate secondary
1. MATERIALS AND DESIGNS
to the transmission of high stresses to the implant-cement-
1.1. Implant Types bone interface and other design flaws. Currently, most linked
implants are semiconstrained: their linking mechanism
There is some confusion regarding the types of implants behaves as a sloppy hinge, allowing some rotational and
available to replace the elbow joint. In general, there are two varus-valgus play. Semiconstrained implants are believed to
broad categories of implants, which differ in the presence or transmit less stress to the implant interfaces, which
absence of a mechanism linking the humeral and ulnar associated with other design improvements have resulted in
more reliable long-term fixation.
*Address correspondence to this author at the Department of Orthopedic The linked semiconstrained implant most commonly
Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; used currently is the Coonrad-Morrey prosthesis (Fig. 1A).
Tel: + 1-507-538-1953; E-mail: Sanchezsotelo.joaquin@mayo.edu

1874-3250/11 2011 Bentham Open

116 The Open Orthopaedics Journal, 2011, Volume 5 Joaquin Sanchez-Sotelo

(A) The humeral component is porous-coated distally and

presents an anterior flange, which increases the rotational
stability of the implant and neutralizes the extension forces
transmitted to the implant interface. The benefit of an
anterior flange has been investigated for other implants as
well [2]. The ulnar component has a plasma-spray metallic
coating in its proximal third. Both components are intended
to be fixed with polymethylmethacrilate. The components
are linked with a cobalt-chrome axis pin, which articulates
with the polyethylene bushings of the ulnar and humeral
components and allows approximately 10 degrees of varus-
valgus and rotational laxity. Other linked implants are
enumerated in Table 1.
Unlinked/Uncoupled Implants
(B)
In this kind of arthroplasty the components are not
mechanically linked. Maintenance of prosthesis congruency
depends on the adequate position of each component,
ligamentous integrity, and the dynamic stabilizing effect of
the musculature. Most of these implants provide a more or
less anatomic resurfacing of the distal humerus and proximal
ulna; some incorporate a radial head component. The most
popular unlinked implants are the Souter-Strathclyde and the
Kudo prostheses (Fig. 1B). Other unlinked implants are
listed in Table 1.
1.2. Advantages and Disadvantages of the Different
Kinds of Implants
The clinical outcome and long-term survivorship differs
from implant to implant, and the results obtained with a
given linked or unlinked implant cannot be extrapolated to
other members of the same implant family. However, there
are a few advantages and disadvantages of each of these two
design philosophies (Table 2).
Linked implants ensure joint stability, even in the
(C)
presence of severe bone loss or ligamentous insufficiency.
These implants not only eliminate one of the main
complications of unlinked implants, namely dislocation, but
also allow a more aggressive soft-tissue release in patients
with preoperative stiffness and deformity, which allows
more reliable restoration of elbow motion. On the other
hand, the increased constrained associated with implant
linking results in increased tension on both the joint surface
and the interfaces, which may facilitate polyethylene wear
and component loosening. Semiconstrained implants did
represent an improvement, but well-fixed semiconstrained
implants are at risk for accelerated wear in the presence of
ligamentous imbalance.
Some linked implants also allow replacement in the
presence of severe bone loss. Many unlinked designs require
the humeral condyles and ulnar notch for component
fixation. Bone loss compromises fixation of this kind of
components and may render the medial or lateral ligament
complexes insufficient if the epicondyles are affected. In
addition, patients with severe preoperative stiffness may
require non-anatomic implantation of the humeral
component to raise the joint line, which makes the use of
unlinked implants more complicated.
Fig. (1). Some examples of implants used to replace the elbow
joint: (A) Coonrad-Morrey linked semiconstrained elbow However, linked implants do have substantial
arthroplasty, (B) Kudo unlinked minimally constrained elbow disadvantages, especially when they are constrained. In those
arthroplasty, (C) Latitude anatomic linkable prosthesis. situations where the remaining bone stock and ligamentous
Total Elbow Arthroplasty The Open Orthopaedics Journal, 2011, Volume 5 117

Table 2. Advantages and Disadvantages of Linked and Unlinked Prosthesis

Linked Unlinked

Advantages • Ensure joint stability • Less constrained implants may be associated with a lower
• May be used in the presence of ligamentous insufficiency risk of wear, loosening and osteolysis
• May be used in the presence of severe bone loss • Less bony-invasive, which may be beneficial if revision or
resection are required
• Better range of motion (soft-tissue release and non-anatomic
implantation) • Some anatomic humeral components may be used as
hemiarthroplasty
Disadvantages • Increased constrained may result in increased tension to the • Most require more accurate component positioning in order
interface and higher risk of mechanical failure secondary to to ensure proper articular tracking
wear and/or loosening • It is possible to subluxate or dislocate the joint
• More extensive canal invasion, potentially complicating • Difficult to use when there is the need to compensate for
revision surgery bone loss or ligamentous insufficiency
• Cannot be used as hemiarthroplasty • Limited ability for soft-tissue release or non-anatomic
• Component linking may make implantation more difficult implant positioning in patients with stiffness
• Possible failure of the linking mechanism

structures are adequate, unlinked implants are at least • The components may be linked after being
theoretically at less risk of mechanical failure secondary to completely seated.
wear, osteolysis and loosening. As a general rule, the stems
The Latitude system probably is the best example of this
of unlinked implants are shorter; this is especially beneficial
new generation of elbow arthroplasty (Fig. 1C). This
when revision or resection is required. Some anatomic
modular system is linkable, meaning that the surgeon may
unlinked humeral components may also be used as choose at the end of the case to leave the implant linked or
hemiarthroplasties.
unlinked depending on his intraoperative assessment of
The need for a radial head implant is controversial. On stability. In addition, this system allows conversion of a
one side, patients with an arthritic radial head or a previous distal humerus hemiarthroplasty to a total elbow arthroplasty
radial head resection may benefit from the use of a radial without revising the humeral stem.
implant, which may increase stability and result in a greater
improvement on the lateral side of the joint. However, from 2. INDICATIONS AND CONTRAINDICATIONS
a technical point of view it is difficult to achieve proper Inflammatory arthropathies, such as rheumatoid arthritis,
alignment and tracking of the radial head implant, and this represent the classic indication of elbow arthroplasty. Those
component is potentially one more source or wear, osteolysis patients with more severe involvement (Mayo Clinic stage
and loosening. III to V) experience great improvements in pain and
Currently published data seem to favour the use of linked function. In addition, the polyarticular nature of these
semiconstrained implants. Little et al. [3] recently published conditions may limit the overall activity level of these
a systematic review of the literature on elbow arthroplasty. patients, with a low rate of wear and loosening. In the earlier
The overall revision rate has been similar for linked and stages of rheumatoid arthritis, there is usually enough bone
unlinked implants (11 vs 13 per cent). However, stock and ligamentous integrity to allow the use of unlinked
radiographic loosening seems to be higher with unlinked implants.
implants (especially the humeral component of the Souter The successful outcome of elbow arthroplasty in
prosthesis). The functional results are similar with the inflammatory conditions prompted its use for the treatment
exception of elbow extension, which seems to be better with of other conditions (Table 3). Posttraumatic elbow
linked implants. On a separate study, Levy et al. reported a osteoarthritis represents one of the most difficult conditions
higher rate of revision for unlinked compared to linked to treat. Some patients may improve with alternative surgical
implants [4]. procedures, such as interposition arthroplasty, but pain relief
is not completely reproducible and some patients may
1.3. Modern Implants
experience postoperative instability. Elbow arthroplasty
Recently designed implants have maintained some of the provides a more reliable outcome, but these younger, more
classic features recognized to improve the outcome of elbow active patients are at risk for early mechanical failure [1]. In
arthroplasty (such as the use of a flange), but provide three general, elbow arthroplasty is best avoided in patients under
potential advantages: the age of sixty.
• The bearing surface design allows the use of a thicker Acute comminuted distal humerus fractures in elderly
polyethylene subjected to less contact pressure. patients or those with previous articular degeneration has
emerged as one of the most common indications for elbow
• The instrumentation and design allow a more
arthroplasty in some countries [5]. Stable internal fixation is
anatomic reconstruction with more attention being
difficult to obtain in these circumstances, and arthroplasty is
paid to reproduction of the anatomic center of
rotation. used successfully for other fractures (femoral neck, proximal
humerus). It is important to emphasize that this is a selective
118 The Open Orthopaedics Journal, 2011, Volume 5 Joaquin Sanchez-Sotelo

indication, as most patients with distal humerus fractures are preparation of the humeral and ulnar canals with rasps and
best treated with open reduction and internal fixation. broaches. The author uses the Coonrad-Morrey system. With
Table 3. Main Indications for Elbow Arthroplasty
this system, the humeral side is prepared first after exposing
the joint and releasing the lateral and medial collateral
ligaments. The humeral canal is identified and used as a
• Chronic inflammatory arthropaties
reference to cut a yoke-shaped segment of the distal humerus
• Posttraumatic osteoarthritis to accommodate the distal part of the humeral component.
• Acute distal humerus fractures Next, the canal is prepared to accept the stem and the
• Distal humerus Nonunions anterior cortex of the distal humerus is exposed for future
• Extreme intrinsic stiffness/ankylosis contact with a bone graft placed behind the anterior flange of
• Large posttraumatic bone defects the humeral component. The ulnar canal is opened at the
• Primary osteoarthritis (rare) mid-portion of the trochlear notch and the canal prepared
• Haemophilic arthropathy with right or left broaches. The components are then
• Reconstruction after tumor resection cemented in place with antibiotic-loaded polymethylmetha-
crylate placing a bone graft between the anterior humeral
cortex and the humeral flange. The components are then
Other indications for elbow arthroplasty include the linked together.
salvage of distal humerus nonunion in elderly patients, large The ulnar canal is usually relatively narrow, which
posttraumatic defects, as well as elbow reconstruction after requires the use of small flexible cannula to introduce the
tumor resection. Primary osteoarthritis of the elbow usually cement, which should be applied very early. Preoperative
affects younger patients and is treated successfully in many stiffness or deformity usually requires extensive soft-tissue
patients with joint debridement procedures such as balancing and releases. Limited extension may be corrected
osteocapsular arthroplasty. by anterior capsular release and proximal placement of the
3. SURGICAL TECHNIQUE OVERVIEW humeral component with elevation of the joint line. Limited
flexion is corrected by posterior capsular release and
3.1. Surgical Exposure occasionally resection of the anterior aspect of the coronoid.
Most of the surgical approaches used for implantation of 3.3. Postoperative Management
an elbow arthroplasty require mobilization of the elbow
extensor mechanism. Subcutaneous ulnar nerve transposition The goal of the early phase of postoperative treatment
is routinely performed by most surgeons. The author’s consists in limited postoperative edema. The elbow is
preferred exposure is the triceps-reflecting Bryan-Morrey immobilized in extension with an anterior plaster splint and a
approach [6]; other surgeons prefer to split the triceps or use bulky dressing and the upper extremity is kept elevated.
an extended lateral-sided Köcher approach. Triceps- When a linked arthroplasty is used, elbow motion without
preserving approaches are desirable whenever possible [7]. protection may be initiated in the first few days after surgery
depending on the aspect of the wound and the quality of the
The approach described by Bryan and Morrey involves extensor mechanism reconstruction. Most surgeons keep the
detaching the triceps off the olecranon reflecting it from elbow immobilized for approximately two weeks after using
medial to lateral maintaining its continuity with the anconeus an unlinked elbow arthroplasty to protect the ligamentous
and the forearm fascia. This approach provides ample structures and decrease the risk of instability. A nocturnal
exposure of the joint and allows a secure reconstruction of extension splint is useful for the first few weeks after surgery
the extensor mechanism, although it is associated with some when there is a marked preoperative flexion contracture.
risk of lateral subluxation of the triceps and weakness in Elbow extension against resistance should be avoided
extension. whenever the extensor mechanism has been violated for
Splitting the triceps in the midline with detachment of its exposure.
medial and lateral halves from the olecranon also provides a Polyethylene wear is the main limiting factor for the
good exposure. The main advantage of this approach is survivorship of current elbow designs. Prior to surgery
maintenance of the extensor mechanism centralized over the patients should understand the need to protect their upper
olecranon, but transmuscular approaches are in general less extremity. Empirically, patients are recommended to avoid
appealing and the repair of the medial half is some times lifting with the involved upper extremity more than 2 pounds
unsatisfactory. on a repetitive basis or more than 10 pounds on a single
In some specific circumstances, it is possible to perform event.
the replacement by working on both sides of the triceps [7,
4. CLINICAL RESULTS
8]. This approach is mostly indicated in the presence of a
substantial bone defect at the distal humerus (secondary to 4.1. Chronic Inflammatory Arthritis
trauma or tumor resection), as well as in acute distal
humerus fractures and nonunion of the distal humerus, where Several studies have documented the outcome of elbow
the distal fragments are resected. arthroplasty in rheumatoid arthritis using both linked and
unlinked implants. Gill and Morrey [9] published the results
3.2. Bony Preparation and Component Insertion obtained in 78 consecutive rheumatoid elbows using the
Coonrad-Morrey design. At most recent follow-up, 97 per
The bony preparation is different for each particular
cent of the patients had no or mild pain and the mean arc of
system. Most components are stemmed and require
motion was from 28 degrees of extension to 131 degrees of
Total Elbow Arthroplasty The Open Orthopaedics Journal, 2011, Volume 5 119

flexion. The main complications of this series included deep Van der Lugt et al. [11] published the results obtained in
infection (2 cases), aseptic loosening (2 cases), triceps 204 rheumatoid elbows replaced using the Souter-
avulsion (3 cases), periprosthetic fractures (2 cases), and Stractclyde prosthesis and followed for a mean of 6.4 years.
ulnar component fracture (1 case). Survivorship free of At most recent follow-up, only 6 patients complained of pain
revision was 92.4% at ten years (Fig. 2). Gschwend et al. at rest. Complications included infection (10 cases), humeral
[10] published the results using the GSB III prosthesis in 65 loosening (22 cases), and dislocation (4 cases). Kudo et al.
elbows, 32 of which were rheumatoid, followed for a [12] published the results obtained in 43 elbows replaced
minimum of 10 years. Overall clinical results were with the Kudo prosthesis and followed for a mean of three
satisfactory and the main complications included infection (6 years; good or excellent results were obtained in
per cent), loosening (4.6 per cent) and component approximately 86% of the patients, although some
disengagement (13.6 per cent). experienced loss of extension. Willems and De Smet
published the results of 36 Kudo prosthesis in rheumatoid
(A)
elbows; the main reported complications included infection
(1 case), instability (2 cases), and loosening (6 cases) [13].
We recently reviewed the Mayo Clinic experience using
a linked semiconstrained elbow arthroplasty in rheumatoid
arthritis. 461 consecutive Coonrad-Morrey arthroplasties
were followed for a mean of 8 (range, 2 to 25) years. At
most recent follow-up, 418 implants (90.7%) had not been
revised, 10 (2.2%) had been removed or revised for
infection, 25 (5.4%) had been revised for loosening, 8
elbows (1.7%) had been revised for polyethylene wear, and 3
patients underwent internal fixation of a periprosthetic
fracture. Seventeen additional elbows required debridement
for deep infection (overall infection rate, 5.8%). Revision for
polyethylene wear was performed between 10 and 17 years
after surgery in all but one of the eight elbows. Twenty-year
survivorships were 90% (95CI 79-94%) free of revision for
loosening, 78% (95CI 65-89%) free of revision for
mechanical failure, and 72% (95CI 58-85) free of revision
for mechanical failure or deep infection.
In general, most patients with rheumatoid arthritis
experience satisfactory pain relief and functional
improvement with both linked and unlinked implants. Most
patients also maintain a good arc of motion and the rate of
mechanical failure is small. Some authors believe that the
outcome of elbow arthroplasty is similar to the outcome of
hip and knee arthroplasty in rheumatoid patients [9, 10].
Linked arthroplasties allow the treatment of a wider
spectrum of pathology, including patients with more
extensive involvement, bone defects and instability.
4.2. Trauma
(B) Posttraumatic Osteoarthritis
This is one of the most common conditions affecting the
elbow joint. Postoperative pain and stiffness are common
sequels of elbow trauma. The first step in the evaluation of
these patients is to determine how much the articular surface
contributes to the patient’s symptoms. Patients with a
symptomatic articular surface experience pain with resisted
flexion and extension in the mid-arc of motion. The status of
the articular surface may be evaluated with radiographs and
CT scan.
When the articular surface is responsible for most
symptoms, the alternative surgical options are somewhat
limited and not totally satisfactory. Arthroscopic
debridement is more reliable for impingement pain.
Interposition arthroplasty includes placement of a layer of
cutis, fascia lata or Achilles tendon allograft interposed
Fig. (2). Anteroposterior (A) and lateral (B) radiographs after elbow between the humerus and ulna and temporary distraction of
arthroplasty for rheumatoid arthritis.
120 The Open Orthopaedics Journal, 2011, Volume 5 Joaquin Sanchez-Sotelo

the joint with an articulated external fixator for patients in this situation, elbow arthroplasty probably
approximately 6 weeks. This procedure is more reliable for represents a better alternative.
restoration of motion than pain relief [14, 15]. Other
There are different philosophies for the use of elbow
procedures, such as osteoarticular allografts or elbow fusion,
arthroplasty in distal humerus fractures. The author’s
have a high rate of complications [16] or are poorly accepted preferred strategy is to work through a bilaterotricipital
by patients [17]. Elbow arthroplasty is very attractive as it
approach, resect the fractured fragments, and complete the
provides the best early functional results; however, it is
arthroplasty. When the distal fragments are resected, the
associated with a worrisome rate of mechanical failure
collateral ligament complexes and the flexor-pronator and
especially in younger patients [18].
extensor-supinator groups are detached. A linked
Schneeberger et al. [18] published the results of a study arthroplasty is needed to compensate for the ligamentous
of 41 patients with posttraumatic osteoarthritis using the insufficiency. The forearm muscular groups are sutured to
Coonrad-Morrey prosthesis. The mean age of the patients at the triceps to seal the joint; interestingly, resection of the
the time of surgery was 57 years (range, 32 to 82 years) and humeral condyles does not seem to affect grip strength or
the mean follow-up time was five years. Seventy-three per strength in flexion, extension, pronation or supination [20].
cent of the patients had no or mild pain and the results were Other philosophy consists in fixing the condyles to preserve
considered satisfactory in 83 per cent of the cases. However, the integrity of the collateral ligaments and replace the
there was a 27 per cent complication rate, including five articular surface with a distal humerus hemiarthroplasty or a
ulnar component fractures and two revisions for total elbow replacement.
polyethylene wear. These authors concluded that elbow
The outcomes of total elbow arthroplasty in selected
arthroplasty should be relatively contraindicated in patients
patients with complex distal humerus fractures are quite
planning to perform substantial physical activities with the
satisfactory. Kamineni and Morrey recently reviewed the
involved upper extremity or are not able to comply with the results obtained in a consecutive series of 43 patients
previously mentioned postoperative restrictions.
followed for a mean of seven years [5]. Most patients
We recently updated the Mayo Clinic experience with achieved a satisfactory Mayo Elbow Performance Score and
total elbow arthroplasty in post-traumatic osteoarthritis. the mean arc of motion was from 24 degrees of extension to
Eighty-five consecutive patients underwent semiconstrained 131 degrees of flexion (Fig. 3). However, nine patients
TEA for post-traumatic arthritis. Sixty-nine elbows with a required a reoperation, including 5 cases of component
retained primary prosthesis were followed for an average of revision. Other authors have published similar outcomes [21-
9.1 years (range 2-20.5). Sixteen primary arthroplasties 24]. Frankle et al. [21] performed an interesting comparative
(19%) failed secondary to isolated bushing wear (7), study between internal fixation and arthroplasty in 24
infection (4), component fracture (3), or component fractures affecting women over 65 years old and obtained a
loosening (2). Four additional arthroplasties showed better in the arthroplasty group.
radiographic signs of loosening and three had substantial Distal Humerus Nonunion
radiographic wear. Total elbow arthroplasty was associated
with statistically significant gains in pain relief, motion, and The salvage of distal humerus nonunion in selected
MEPS scores (p<0.002). Forty seven (68%) patients patients represents a good indication for elbow arthroplasty.
achieved good or excellent clinical results using objective Most distal humerus nonunions are treated with internal
criteria and 74% were subjectively satisfied with their fixation and bone grafting. However, elderly patients with
outcomes at final follow-up. Kaplan Meier analysis osteopenia and very limited bone stock may be benefit more
demonstrated a 15-year survivorship of 70% for revision or from elbow arthroplasty. Morrey and Adams published the
resection for any reason, 73.7% for revision for mechanical results obtained in 36 patients with a mean age of 68 years
failure, and 90.2% for aseptic loosening. followed for an average time of 4 years after elbow
arthroplasty for distal humerus non-union [25]. Results were
The relatively high mechanical failure rate of elbow
rated as satisfactory in 86 per cent of the cases; there were
arthroplasty in patients with posttraumatic osteoarthritis has
been the main driving force for the development of newer two infections and three patients with excessive polyethylene
wear. We recently updated the Mayo Clinic experience using
implants with supposedly better wear patterns. There are no
elbow arthroplasty for the salvage of 92 distal humerus
published studies on the outcome of these new designs. An
nonunion. At a mean follow-up of 6.7 years (range, 2 to 20
alternative strategy in younger patients is to offer them an
years), 79 per cent of the patients had no or mild pain and
interposition arthroplasty as their first procedure as long as
mean range of motion was from 22 degrees of extension to
they understand that pain relief is not reliable; fortunately,
the outcome of replacement after failed interposition 135 degrees of flexion. Complications included aseptic
loosening in 16 patients, component fracture in 5 patients,
arthroplasty is equivalent to that of patients without previous
deep infection in 5 patients and bushing wear in one patient.
interposition [19].
Distal Humerus Fractures 4.3. Other Indications

Open reduction and internal fixation is the treatment of Total elbow arthroplasty has also been successfully used
choice for most distal humerus fractures. However, the in patients with severe stiffness or ankylosis [26], gross
outcome of internal fixation may be compromised in a instability secondary to large bony defects [27], haemophilic
selective group of patients with extensive comminution, arthropathy [28], and reconstruction after tumor resection
osteopenia or previous articular pathology. For elderly [29].
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(A) 5. COMPLICATIONS
5.1. Infection
Deep periprosthetic infection affects the elbow more
commonly than other joints. This is attributed to the thin
soft-tissue envelope of the elbow as well as the higher risk of
infection in patients with relative immune suppression
secondary to inflammatory conditions or failed previous
surgical procedures for trauma. Currently, the incidence of
infection after elbow arthroplasty is estimated to be between
2 and 4 per cent [3, 30] Antibiotic-loaded polymethylmetha-
crylate is used routinely for implant fixation in an effort to
decrease the rate of infection. Acute infections may be
treated with irrigation, debridement, polyethylene exchange
and retention of the components. Chronic infections may be
treated with two-stage reimplantation or resection depending
on the nature of the infection, patient needs and remaining
bone and soft-tissues.
5.2. Ulnar Neuropathy
The overall rate of ulnar neuropathy is difficult to estimate
as patients with sensory symptoms are not reported accurately
on most published studies about elbow arthroplasty. The
incidence of severe ulnar neuropathy probably is around 5 per
cent [3]. Most surgeons recommend routine subcutaneous ulnar
(B) nerve transposition at the time of arthroplasty to prevent
postoperative ulnar nerve dysfunction.
5.3. The Extensor Mechanism
The rate of extensor mechanism dysfunction is also
difficult to analyze in the published literature and probably is
underestimated. In Little et al.’s systematic review of the
literature the incidence of triceps insufficiency was 3 per
cent [3]. Poor soft-tissue quality as present in many patients
with rheumatoid arthritis may affect the quality of the triceps
repair at the end of surgery. Patients with symptomatic
dysfunction of the extensor mechanism may benefit from
surgical reconstruction of the extensor mechanism using
either an anconeus rotation flap or an Achilles tendon
allograft [31].
(C) 5.4. Instability
Unlinked elbow arthroplasty may be complicated by
subluxation or dislocation. The rate of dislocation is
approximately 5 per cent; the overall rate of instability
(dislocation or subluxation) is about 15 per cent [3]. There are
different treatment options. Dislocation presenting in the first
few weeks after surgery may respond to closed reduction and
immobilisation. However, most patients with instability require
revision surgery for ligamentous reconstruction or revision to a
linked elbow arthroplasty [32].
5.5. Mechanical Failure
The overall rate of aseptic loosening after elbow
arthroplasty probably ranges between 5 and 10 per cent, and
it is different for different implant designs. According to
Little et al., the published aseptic loosening rate is 2 per cent
for the Coonrad-Morrey prosthesis, 8 per cent for the Souter
prosthesis, and 18 per cent for the Kudo prosthesis [3].
Fig. (3). Postoperative radiograph (A) and final range of motion (B Polyethylene wear and osteolysis, component fracture, and
and C) after elbow arthroplasty for an acute distal humerus fracture component disengagement are additional modes of
in an elderly female patient. mechanical failure whose rate is difficult to estimate.
122 The Open Orthopaedics Journal, 2011, Volume 5 Joaquin Sanchez-Sotelo

Polyethylene wear probably is the limiting factor for the dysfunction. More recent studies have documented a high
durability of elbow arthroplasty in young active patients. success rate with revision techniques used in the presence of
bone loss, including cortical strut allografts, impaction
5.6. Periprosthetic Fractures grafting and allograft-prosthetic composites [33, 34, 36, 37].
Elbow periprosthetic fractures are classified based on the In general terms, allograft-prosthetic composites have
location of the fracture, the fixation of the components and provided inferior results compared to other techniques.
the need to use special reconstructive techniques for bone
7. SUMMARY
loss [33]. Most fractures of the humeral condyles may be
treated nonoperatively provided they are not associated with The field of elbow arthroplasty continues to experience
instability in the case of unlinked prosthesis. Most substantial improvements. Currently, elbow replacement
periprosthetic fractures require component revision and represents a successful treatment alternative for patients with
internal fixation using plates or cortical strut allografts [33, inflammatory conditions as well as selected patients with
34]. posttraumatic osteoarthritis, elderly patients with low,
comminuted distal humerus fractures, the salvage of distal
6. REVISION SURGERY humerus nonunion, ankylosis, haemophilic arthropathy, and
The increasing use of elbow arthroplasty, especially in elbow reconstruction after tumor resection. Some linked
younger patients with increased functional demands, has arthroplasty designs seem to be associated with a better
resulted in a substantial increase in the prevalence of revision outcome and allow the management of a wider range of
surgery. Most revisions surgeries require the use of a linked pathology. There is interest in the development of improved
prosthesis, as the severity of bone loss and ligamentous designs which will decrease the rate of polyethylene were
insufficiency in the revision setting rarely permits the use of and mechanical failure in higher demand patients and
an unlinked implant. provide increased flexibility in the primary and revision
setting. The role of distal humerus hemiarthroplasty, linkable
A careful preoperative evaluation of the patient prior to
implants and components for the radial head need further
revision surgery is critical for success. The physical investigation.
examination should consider the condition of the skin,
location of previous incisions, range of motion, joint The success of elbow arthroplasty depends greatly on the
stability, muscle function and strength, as well as the surgeon’s familiarity with the anatomy and surgical appro-
location and function of the ulnar nerve. The possibility of aches to the elbow joint, the proper selection and implant-
infection should always be considered and investigated with ation of prosthetic components, and compliance with postop-
baseline laboratory studies including white cell count, erative recommendations. Although elbow arthroplasty is
sedimentation rate and C reactive protein. Joint aspiration for sometimes the only option to improve pain and function in a
cell count and cultures should probably be considered in wide range of patients, this procedure may be associated
every patient and is mandatory if there is a high suspicion of with complications which may be difficult to solve, inclu-
infection or the parameters mentioned above are elevated. ding infection, extensor mechanism dysfunction, peripros-
Preoperative radiographs should also be analyzed carefully thetic fractures, wear, loosening and osteolysis. Fortunately,
to evaluate the fixation of the components and the severity of revision techniques developed over the last few years allow
bone loss. successful treatment of some of these complications.
A few basic principles apply to all revision cases. The REFERENCES
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Received: October 9, 2009 Revised: April 10, 2010 Accepted: July 10, 2010

© Joaquin Sanchez-Sotelo; Licensee Bentham Open.

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