High-yield overview

Medial posterior approach (Bryan-Morrey) with triceps-on technique | advanced

Surgical Imaging

Total elbow replacement implant components showing humeral and ulnar stems — Linked total elbow replacement system: cemented humeral and ulnar stems with snap-fit articulation. The bushing mechanism allows ~7° varus-valgus laxity to reduce bone-implant stress.Credit: Wieser K et al., BMC Musculoskelet Disord 2015 (PMC4799294) — CC BY 4.0

Close-up articulation of total elbow replacement showing polyethylene bushing — Close-up of the articulating mechanism: polyethylene bushing links humeral and ulnar components, providing semi-constrained articulation with controlled load transfer.Credit: Wieser K et al., BMC Musculoskelet Disord 2015 (PMC4799294) — CC BY 4.0

Pre-operative clinical photograph of severely deformed elbow in rheumatoid arthritis — Pre-operative presentation: severe rheumatoid elbow deformity with marked valgus angulation, soft-tissue wasting, and prominent bony landmarks — typical TER indication.Credit: Cil A et al., J Shoulder Elbow Surg 2015 (PMC5040571) — CC BY 4.0

Nine-panel case series showing pre-op X-rays, tumor excision, TER insertion, and post-op X-rays — Tumour-related TER case series: (top) pre-op AP/lateral X-rays; (middle) en-bloc bone excision and trial component insertion with arrow marking implant position; (bottom) post-op AP and lateral radiographs showing well-fixed linked TER.Credit: Koh KH et al., J Shoulder Elbow Surg 2014 (PMC3868144) — CC BY-NC 3.0

Critical Danger Structures

Danger 1: Ulnar Nerve

Most at risk structure in TER. Location: Posterior to medial epicondyle in cubital tunnel, then between heads of FCU. Risk: Traction, compression from prosthetic bulk, scar entrapment. Prevention: Identify and anterior-transpose at start of procedure, protect throughout, mark with vessel loop. Palsy occurs in 2-5% causing clawing of ring and little fingers.

Danger 2: Radial Nerve

At risk in lateral dissection and capsule release. Location: Lateral intermuscular septum, passes anterior to lateral epicondyle into radial tunnel. Risk: Aggressive anterior capsule release, lateral retraction, power burr near radial head. Prevention: Stay posterior to lateral epicondyle, avoid blunt retractors anterolaterally. Injury causes wrist drop.

Danger 3: Brachial Artery

Passes through antecubital fossa anterior to elbow joint. Location: Medial to biceps tendon, bifurcates into radial and ulnar arteries at neck of radius level. Risk: Anterior capsule release, aggressive retraction, saw injury during distal humerus cuts. Prevention: Avoid anterior retractors beyond capsule, control anterior dissection meticulously.

Danger 4: Medial Antebrachial Cutaneous Nerve

Superficial sensory nerve crossing medial surgical field. Location: Pierces deep fascia proximal to medial epicondyle, crosses anterior to epicondyle in superficial fat. Risk: Skin incision, superficial dissection, retraction. Prevention: Gentle superficial dissection with skin hooks, identify early, protect throughout. Injury causes medial forearm dysaesthesia and painful neuroma.

Danger 5: Triceps Mechanism (Bryan-Morrey)

The entire triceps-on approach depends on a secure periosteal sleeve repair. Risk: Triceps avulsion from olecranon results in permanent extensor lag and functional failure. Prevention: Reflect periosteal sleeve sharply off olecranon tip as continuous sheet, reattach through bone tunnels with non-absorbable suture (Krackow or Mason-Allen), protect repair for 6 weeks post-operatively.

Mnemonic

RULERULE — Indications for Total Elbow Replacement

Mnemonic

LINKLINK — Choosing Between Linked and Unlinked Implants

Primary Indications

Rheumatoid Arthritis (Primary Indication)

Most common indication for TER worldwide
Larsen grade 3-5 (moderate-to-severe articular destruction)
Failed adequate medical management (DMARDs, biologics)
Pain and disability disproportionate to damage on imaging
Evidence: Gschwend et al. (multiple series) and Morrey BF JBJS 1993 demonstrate good long-term results
Survival: 85-92% at 10 years in RA population (lower demand than post-traumatic group)

Comminuted Distal Humerus Fracture in Elderly

Level I evidence — McKee MD et al., JSES 2008: multicentre prospective RCT of ORIF versus primary semiconstrained TER in patients over 65 with displaced intra-articular (OTA 13C) distal humeral fractures. TER gave significantly better Mayo Elbow Performance Scores at every time point to 2 years (e.g. 86 versus 73 at 2 years). Crucially, 5 of 21 patients randomised to ORIF were converted to TER intra-operatively because stable fixation could not be achieved
Cobb TK and Morrey BF, JBJS Am 1997 is the earlier foundational case series (20 patients, mean age 72, 15 excellent and 5 good MEPS results) that first established primary TER as a treatment for acute comminuted distal humeral fracture — it is a retrospective series, NOT a comparative ORIF-versus-TER trial; the authors explicitly stated it is not an alternative to osteosynthesis in younger patients
TER advantages in this group: more predictable functional recovery, earlier mobilisation, shorter operative time, lower conversion/re-operation pressure when fixation is unachievable
Current indications: age usually over 65, significant articular comminution, osteoporotic bone preventing stable fixation, low functional demand
Contraindicated if active infection, insufficient bone for implant seating, young active patients

Post-Traumatic Arthritis

End-stage arthritis following malunited fractures, chronic instability, or failed ORIF
Often involves hardware removal as first stage
Results generally inferior to RA cohort due to younger patients, higher demands
Careful patient selection and activity counselling essential
Arthrodesis remains an option in young high-demand patients

Other Indications

Primary osteoarthritis (rare — usually over 65, low demand)
Tumour resection (distal humerus sarcoma requiring wide resection)
Revision of failed elbow arthroplasty

Contraindications

Absolute:

Active infection (local or systemic)
Non-functional deltoid and biceps (unable to stabilise arm)
Young high-demand patient without understanding/acceptance of activity restrictions
Insufficient bone stock to seat implant components

Relative:

Prior osteomyelitis / chronic infection
Neuropathic arthropathy
Young active patient (less than 50 years) — consider alternatives
BMI over 40 (increased surgical difficulty and complication risk)

Evidence Base

Linked vs Unlinked — What the Evidence Shows

Linked (Semiconstrained):

Coonrad-Morrey implant: most published long-term data
Morrey BF and Adams RA JBJS Am 1992: semiconstrained arthroplasty in RA establishing efficacy and survivorship
Gill DR and Morrey BF JBJS Am 1998: 10-15 year follow-up of the Coonrad-Morrey in RA — 92.4% implant survival, 86% good/excellent and 14% fair/poor by MEPS
Lower technical demand — more forgiving of soft tissue imbalance

Unlinked:

Kudo type-5, Souter-Strathclyde designs
Require intact collateral ligaments and good bone stock
Higher instability risk if not correctly selected
Advantages: lower bushing wear, preserves more physiological kinematics if well-balanced

Comparative:

No large RCT comparing linked vs unlinked directly
Registry-style data (Plaschke JSES 2014, 324 procedures) show the unlinked design carries a relative risk of revision of 1.9 versus linked, supporting the preference for linked implants in most contemporary practice
Systematic reviews suggest similar functional outcomes when correctly selected
Most surgeons favour linked designs for RA due to reliability

Clinical Decision Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOAdvanced

CLINICAL PROMPT

"A 74-year-old woman with longstanding rheumatoid arthritis presents with bilateral elbow pain and inability to perform activities of daily living. Both elbows show Larsen grade 4 destruction on X-ray. She is on methotrexate and etanercept. How do you manage her?"

PRACTICAL APPROACH

This is a classic indication for total elbow replacement in a patient with end-stage bilateral RA. My priority is a systematic approach. Pre-operative assessment: I need a thorough medical work-up including inflammatory markers (CRP, ESR), haematological profile, and nutritional assessment — RA patients on immunosuppression are at higher risk of infection and poor wound healing. I would liaise with her rheumatologist regarding immunosuppressive management: methotrexate should be continued perioperatively (evidence supports this in lower infection risk), but biologics (etanercept) should be held for at least one dosing interval before surgery to reduce infection risk — typically 2-4 weeks for etanercept. For bilateral involvement, I would stage the surgeries — typically 6-12 weeks apart — to allow functional recovery of the first side before operating on the second. The dominant or more symptomatic side is usually done first, but this must be individualised. Having a functional contralateral arm during recovery of the operative side is a key safety consideration. Surgical planning: Both elbows require linked semiconstrained TER (Coonrad-Morrey type) given the Larsen grade 4 changes with likely ligament insufficiency and bone erosion. I use the Bryan-Morrey approach and routinely transpose the ulnar nerve. Radial head excision is performed if the radiohumeral joint is involved, which it typically is in RA. Critical counselling: Lifetime activity restriction less than 5 kg single-lift and less than 1 kg repetitive lift. For a bilateral TER patient this means careful functional planning — she must understand she will never carry heavy loads with either arm. Realistic outcomes: 85-92% good/excellent at 10 years in RA, pain relief is the most reliable benefit, ROM improvement variable but functional arc of 30-130 degrees targeted.

CLINICAL SCENARIOAdvanced

CLINICAL PROMPT

"A 47-year-old male construction worker sustains a comminuted distal humerus fracture in a fall. CT shows three-part intra-articular fracture with poor bone quality (T-score minus 2.8 on DEXA). He is otherwise fit. Discuss your management including the evidence for TER versus ORIF."

PRACTICAL APPROACH

This is a challenging case because he is relatively young (47) yet has poor bone quality and a complex fracture pattern that challenges surgical fixation. Initial assessment: The fracture characteristics (three-part, comminuted, intra-articular) and bone quality (T-score minus 2.8 — osteoporosis) are critical. ORIF is technically demanding and depends on adequate bone stock for screw purchase. CT planning is essential to map the fracture pattern, assess articular comminution, and evaluate medial and lateral column integrity. ORIF considerations: This is the standard approach for active patients regardless of age. If adequate fixation can be achieved — dual orthogonal plating (medial and lateral), all articular fragments reduced and stabilised — this preserves the native joint with no activity restrictions. However, with three-part intra-articular comminution and osteoporosis, fixation may be unstable, risking non-union, malunion, or loss of fixation requiring re-operation. Evidence for TER: The Level I evidence is the McKee JSES 2008 multicentre RCT, which randomised patients over 65 with displaced intra-articular distal humeral fractures to ORIF or primary TER and found TER gave better Mayo Elbow Performance Scores to 2 years, with 5 of 21 ORIF patients converted to TER intra-operatively because fixation was unachievable. The Cobb and Morrey JBJS 1997 paper is the earlier retrospective case series (mean age 72) that first popularised the technique. Both cohorts are elderly — this patient is 47. The evidence base for acute TER in patients under 55 is limited and outcomes are generally inferior due to higher activity demands and longer follow-up required. My recommendation: I would attempt ORIF first. At 47, a construction worker, the lifetime activity restriction less than 5 kg single-lift for TER is devastating for his vocation and quality of life. I would use dual orthogonal locking plates, fragment-specific fixation, and possibly bone graft substitute for comminuted areas. If ORIF is genuinely not achievable intra-operatively (assessment in theatre after exposure and fixation attempt), TER is a salvage option in the same setting. I would consent him for both pre-operatively and have implants available. Critical counselling point: If TER is performed, his career as a construction worker is over. This must be discussed explicitly and documented before surgery.

CLINICAL SCENARIOAdvanced

CLINICAL PROMPT

"A patient returns 2 weeks after total elbow replacement with wound breakdown over the posterior medial elbow. There is a 1 cm area of superficial skin loss with some yellowish exudate. The elbow is warm but the patient is systemically well. How do you manage this?"

PRACTICAL APPROACH

Wound breakdown after TER is a serious complication because the medial posterior elbow skin is thin, poorly vascularised (particularly in RA patients on immunosuppression), and lies directly over the implant. Prompt and systematic management is essential. Immediate assessment: Establish the extent of wound breakdown — superficial skin only, or deeper? If I can probe the wound I need to determine: depth of wound (does it reach fascia? does it communicate with joint?), presence of necrotic tissue, quality of surrounding skin. Any sinus tract or joint communication transforms this from a wound problem to a deep PJI requiring urgent surgery. Assess for infection: Temperature, WBC, CRP, ESR — systemic inflammatory markers. Blood cultures if febrile. Send wound swab for MC+S. However, I need to be careful: RA patients have baseline elevated inflammatory markers, and immunosuppression may blunt the response. Classify the problem: - Superficial wound breakdown without deep communication and no systemic sepsis: conservative management may succeed - Deep wound breakdown or joint communication: surgical emergency requiring urgent washout Management algorithm: For this scenario (systemically well, 1 cm superficial breakdown, 2 weeks post-op): I would admit or see urgently, apply appropriate wound dressing (non-adherent, antimicrobial), start empirical oral antibiotics covering skin organisms (flucloxacillin or co-amoxiclav), and review in 48-72 hours. Critical: if not clearly improving or any deepening within 48 hours, urgent theatre for debridement and washout. Surgical management: If within 3-4 weeks of index surgery and superficial, irrigation and debridement with component retention may be possible if components are stable and well-fixed, and the infection is caused by a low-virulence organism. Coverage: I would involve plastic surgery early — a fasciocutaneous or muscle rotation flap (e.g., anconeus) may be needed for coverage. A split-skin graft alone over implant is insufficient. Deep/late infection: Two-stage revision with antibiotic spacer is the gold standard. This patient's RA medications increase infection risk — liaise with rheumatology. Etanercept should be held immediately.

Key Evidence

A multicentre, prospective, randomised, controlled trial of ORIF versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients

Level I

McKee MD, Veillette CJH, Hall JA, et al. • J Shoulder Elbow Surg (2008)

Clinical Implication: Provides the Level I basis for choosing primary semiconstrained TER over ORIF in elderly patients with unreconstructable comminuted intra-articular distal humeral fractures.

Verify on PubMed (PMID 18823799)

Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients

Level IV

Cobb TK, Morrey BF • J Bone Joint Surg Am (1997)

Clinical Implication: The foundational case series that first established primary TER for acute comminuted distal humeral fracture in the low-demand elderly patient; it is a series, not a comparative trial.

Verify on PubMed (PMID 9199378)

The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis: a ten to fifteen-year follow-up study

Level IV

Gill DR, Morrey BF • J Bone Joint Surg Am (1998)

Clinical Implication: Establishes durable long-term pain relief and high survivorship of the linked semiconstrained design in the rheumatoid elbow — the benchmark TER outcome data.

Verify on PubMed (PMID 9759818)

Failure patterns after linked semiconstrained total elbow arthroplasty for posttraumatic arthritis

Level IV

Throckmorton T, Zarkadas P, Sanchez-Sotelo J, Morrey B • J Bone Joint Surg Am (2010)

Clinical Implication: Quantifies the higher failure rate of TER in the younger, higher-demand post-traumatic patient and underpins strict activity-restriction counselling.

Verify on PubMed (PMID 20516319)

Implant survival after total elbow arthroplasty: a retrospective study of 324 procedures performed from 1980 to 2008

Level III

Plaschke HC, Thillemann TM, Brorson S, Olsen BS • J Shoulder Elbow Surg (2014)

Clinical Implication: Large register-linked cohort confirming acceptable medium-term survival and supporting the preference for linked over unlinked implants in most contemporary practice.

Verify on PubMed (PMID 24766794)