Bryan-Morrey posterior triceps-on approach · linked vs unlinked implants · advanced
- Primary indications are rheumatoid arthritis (the most common worldwide), an unreconstructable comminuted distal humerus fracture in the low-demand elderly (McKee 2008 RCT), end-stage post-traumatic arthritis, and rarely end-stage primary OA.
- Choose a linked semiconstrained implant (e.g. Coonrad-Morrey) for RA, instability, bone loss, tumour or revision; reserve an unlinked implant (Kudo, Souter-Strathclyde) for well-preserved ligaments and bone. The linked design allows 7-8 degrees of varus-valgus laxity that reduces stress at the cement-bone interface.
- Implant survival is around 85-90 percent at 5 years and 75-85 percent at 10 years for linked designs in RA; aseptic loosening is the most common long-term failure mode and revision TER carries a 30-40 percent complication rate.
- The Bryan-Morrey approach reflects the triceps medially off the olecranon as a continuous periosteal sleeve (triceps-on); a meticulous repair through bone tunnels is mandatory and protected for 6 weeks.
- Lifetime activity restriction of less than 5 kg single-lift (and less than 1 kg repetitive) is a defining counselling point — failure to counsel is a medicolegal trap.
- The ulnar nerve is the most commonly injured nerve; anterior transposition at the time of TER is standard practice.
When & Why
Indication. A painful, end-stage elbow arthritis or an unreconstructable distal humerus fracture where preserving movement matters more than heavy loading. The four classic indications: - Rheumatoid arthritis — the most common indication worldwide. Larsen grade 3-5 disease (moderate-to-severe articular destruction) that has failed adequate medical management (DMARDs, biologics), with pain and disability disproportionate to the damage seen on imaging. Bilateral involvement is common; 10-year survival is 85-92 percent in this lower-demand population.
- Comminuted distal humerus fracture in the elderly — an unreconstructable, osteoporotic, intra-articular (OTA 13C) fracture, usually in a patient over 65, where stable fixation cannot be achieved. The Level I evidence (McKee 2008 RCT) showed primary semiconstrained TER gave better Mayo Elbow Performance Scores than ORIF to 2 years, and 5 of 21 patients randomised to ORIF were converted to TER intra-operatively because fixation was unachievable.
- End-stage post-traumatic arthritis — following malunited fractures, chronic instability, or failed ORIF (hardware removal is often a first stage). Results are inferior to the RA cohort because patients are younger and higher-demand; arthrodesis remains an option in young high-demand patients.
- Other — primary osteoarthritis (rare, older low-demand patients), tumour resection (distal humerus sarcoma requiring wide resection), and revision of a failed elbow arthroplasty. Contraindications. Absolute: active infection (local or systemic), a non-functional deltoid and biceps unable to stabilise the arm, a young high-demand patient who will not accept the activity restrictions, and insufficient bone stock to seat the components. Relative: prior osteomyelitis or chronic infection, neuropathic arthropathy, a young active patient (under 50 years — consider alternatives), and a BMI over 40. The one decision that matters — linked versus unlinked. Every technique shares the same Bryan-Morrey exposure; the implant choice rests on ligament and bone quality.
e.g. Coonrad-Morrey, Discovery. Provides inherent stability through a polyethylene bushing. Use when ligaments are deficient, bone is eroded, or for instability, tumour or revision. The 7-8 degrees of varus-valgus laxity reduces cement-interface stress versus a fully constrained design. More forgiving — the default for RA.
e.g. Kudo type-5, Souter-Strathclyde. Relies entirely on intact collateral ligaments and good bone stock for stability. Preserves more physiological kinematics and has lower bushing wear if perfectly balanced, but carries a higher instability risk if poorly selected.
No large RCT compares linked versus unlinked directly, but register data (Plaschke 2014, 324 procedures) found the unlinked design carried a relative risk of revision of 1.9 versus linked. Most surgeons therefore favour a linked design for RA.
Consent specifically for the lifetime activity restriction (less than 5 kg single-lift and less than 1 kg repetitive, for life), a small risk of incomplete pain relief, ulnar nerve symptoms, wound problems (the medial elbow skin is thin and poorly vascularised, especially in RA on immunosuppression), and a reoperation or revision risk that rises over time. Setup. Lateral decubitus (preferred for the Bryan-Morrey approach) with the arm draped free over a padded support, flexed 90 degrees across the chest, and a proximal arm tourniquet — gravity assists the medial-to-lateral reflection of the triceps sleeve. Supine-with-arm-across-chest is the alternative and gives easier anaesthetic access. Loupe magnification and meticulous haemostasis are essential — the ulnar nerve and anterior structures are the whole game.
The Operation
The goal is to expose the elbow through the Bryan-Morrey posterior triceps-on approach, remove the articular surfaces, seat a linked (or occasionally unlinked) prosthesis in the humeral and ulnar canals, link the components before the cement sets, and restore a stable, painless flexion-extension arc — all while protecting the ulnar nerve and repairing the triceps sleeve soundly. Exposure anatomy to hold in mind. The distal humerus has two columns: the medial column (arising from the posterior cortex at about 45 degrees, ending at the medial epicondyle and the MCL origin) and the broader lateral column (about 80 degrees, ending at the capitellum and the LCL origin), joined across a thin articular segment (trochlea medial, capitellum lateral) at the olecranon fossa. The proximal ulna contributes the olecranon (triceps insertion) and coronoid (anterior stability, anterior MCL bundle origin) framing the semilunar (trochlear) notch. The ulnar nerve pierces the medial intermuscular septum, runs posterior to the medial epicondyle in the cubital tunnel (roofed by Osborne's retinaculum), and enters the forearm between the two heads of FCU — it must be identified and anteriorly transposed. The carrying angle (10-15 degrees valgus) and the anterior humeral line (which should bisect the capitellum) are the radiographic checks of component alignment.
The Bryan-Morrey triceps-on operation
- Lateral decubitus, arm draped free over a padded support, flexed 90 degrees across the chest, proximal arm tourniquet.
- A midline posterior incision from 8-10 cm proximal to the olecranon tip to about 6 cm distal, curved slightly medially at the tip to keep the scar off the bony prominence.
- Raise thick full-thickness skin flaps medially and laterally to deep fascia.
- Identify the ulnar nerve posterior to the medial epicondyle; trace it proximally through the Arcade of Struthers (if present) and distally into FCU.
- Release the cubital tunnel retinaculum (Osborne's ligament) completely and create a subcutaneous pocket anterior to the medial epicondyle.
- Transpose the nerve anteriorly and protect it with a vessel loop for the rest of the case. Do this before any traction or retraction is applied.
- Identify the medial border of the triceps at the medial epicondyle.
- With sharp dissection (knife or periosteal elevator), elevate the fascia and periosteum as a continuous sheet from the medial epicondyle, including the deep surface of the triceps tendon and its insertion onto the olecranon tip.
- Maintain continuity — no gaps or buttonholes in the sleeve.
- Continue the sleeve elevation over the olecranon tip laterally, incorporating the anconeus with the lateral sleeve.
- Elevate off the lateral epicondyle, preserving the lateral collateral ligament origin where possible.
- The sleeve now reflects the entire extensor mechanism medially, exposing the joint.
- Identify the radiocapitellar joint through the lateral exposure.
- Excise the radial head if it is involved (typical in RA) to improve exposure and balance; preserve the interosseous membrane attachments distally.
- Excise the remaining articular cartilage, osteophytes and loose bodies.
- Identify and protect the anterior capsule — avoid injury to the brachial artery and median nerve anteriorly.
- Assess ligament integrity, which confirms the linked-versus-unlinked decision if not already made.
- Remove the articular surfaces with an oscillating saw while preserving the columnar architecture.
- Open the humeral canal with a starting awl just proximal to the olecranon fossa; ream sequentially to the appropriate size.
- Trial the humeral component and check rotation (aligned with the epicondylar axis; the component sits in 3-5 degrees of external rotation relative to that axis).
- Open the proximal ulnar canal at the midpoint of the olecranon tip.
- Ream carefully, respecting the anterior bow of the ulna.
- Trial the ulnar component and confirm it seats and rotates smoothly against the humeral trial.
- Pulsatile lavage and dry the canals; place a cement plug 1-2 cm beyond the stem tip.
- Insert the ulnar component first with third-generation cement technique (plug, pressurisation, retrograde delivery), then the humeral component, correctly aligned in the flexion-extension plane.
- For a linked design, link the components with the polyethylene bushing before the cement hardens.
- Check the range: aim for 0-130 degrees flexion with full pronation-supination. Remove all excess posterior cement before it sets.
- Return the sleeve to its anatomic position over the olecranon.
- Pass heavy non-absorbable sutures (number 5 FiberWire or equivalent) through bone tunnels in the olecranon in a Krackow or Mason-Allen configuration for secure purchase.
- Repair the fascia on both the medial and lateral sides under appropriate tension; check the repair strength before closure.
- Layered closure; bring the ulnar nerve back to its subcutaneous anterior position or leave it transposed.
Cement technique principles. Third-generation cementing underpins long-term survival: a cement plug 1-2 cm beyond the stem tip, pulsatile lavage to clear marrow fat and debris, retrograde pressurised delivery, the component inserted before the cement reaches its dough phase, and a 2-3 mm circumferential mantle around the stem.
The ulnar nerve is the most commonly injured structure in TER. Identify it posterior to the medial epicondyle and anteriorly transpose it before any retraction. Protect it with a vessel loop throughout, avoid a tight anterior pocket, and decompress it fully at closure. Avoid anterior retractors beyond the capsule (the brachial artery and median nerve lie anteriorly) and blunt retractors anterolateral to the capitellum (the radial nerve passes anterior to the lateral epicondyle into the radial tunnel).
The Bryan-Morrey approach depends entirely on a secure, continuous periosteal sleeve. Reflect it sharply off the olecranon tip, reattach it through bone tunnels with heavy non-absorbable suture (Krackow or Mason-Allen), and protect the repair for 6 weeks — no resisted extension, gravity-assisted extension only. Inadequate repair causes extensor lag and functional failure; complete avulsion is the most feared approach-specific complication.
For a linked implant, link the humeral and ulnar components with the bushing while the cement is still workable, then make the final alignment and range-of-motion adjustments. Confirm at least 0-130 degrees of flexion and full pronation-supination before the cement hardens, and clear all posterior cement.
Aftercare & Complications
Rehabilitation — protect the triceps repair | Phase | Timing | Focus | Key limits | |-------|--------|-------|------------| | Immediate | 0-6 weeks | Posterior splint at 90 degrees flexion, forearm supination, for 5-7 days; then active-assisted ROM | No resisted extension; gravity-assisted extension only; full pronation-supination from day 1 | | Intermediate | 6-12 weeks | Active triceps work against gravity (week 6), light Theraband (week 8), gradual return to light two-handed ADLs | No carrying; protect the repair | | Functional | 12-20 weeks | Driving (surgeon's discretion), return to sedentary then heavier work | Always within the lifetime weight limits | Target a functional arc of 30-130 degrees flexion by 6 weeks. Most patients are independent with light ADLs by 6 weeks, back to sedentary work by 8-10 weeks, and return to heavier work by 16-20 weeks — within the lifetime limits. Lifetime activity restrictions — the defining counselling point
A TER is for low-demand use only, for life: a single-lift limit of less than 5 kg (roughly a full kettle) and a repetitive-lift limit of less than 1 kg. No racquet sports, golf, contact sports or heavy manual work. The polyethylene bushing wears with cyclic loading and the cement-bone interface fatigues with excess stress — aseptic loosening is the direct consequence of exceeding these limits, no matter how good the elbow feels. A young patient (under 55) who cannot accept these restrictions is not a good TER candidate; offer arthrodesis or interpositional arthroplasty instead.
Complications
- Incidence
- 10-15% at 10 years; higher in young, active or post-traumatic patients
- Prevention
- Third-generation cement technique; activity restriction less than 5 kg; correct component alignment
- Management
- Revision TER with longer stems and structural graft; oncology-type implants for major bone loss; 30-40% complication rate at revision
- Incidence
- 3-5% cumulative; higher in osteoporotic RA; the humeral stem tip is the commonest site
- Prevention
- Press-fit distal humeral extension; activity restriction; watch for cortical thinning on serial X-rays
- Management
- Non-displaced with stable components: splint. Displaced with stable implants: ORIF with cerclage or plates. Loose implant: revision with a long stem bridging the fracture
- Incidence
- 2-5% post-operative palsy; minor dysaesthesia up to 10%; rarely permanent
- Prevention
- Anterior transposition at the outset; vessel-loop protection throughout; full decompression at closure
- Management
- Expectant — 70-80% recover by 3-6 months. EMG or NCS at 6-8 weeks; re-explore if no recovery by 3 months
- Incidence
- 5-10% wound complications; deep infection 3-7%; higher in RA on immunosuppression, post-radiotherapy or revision
- Prevention
- Full-thickness flaps; tension-free closure; minimise retractor pressure; delay surgery in an RA flare
- Management
- Superficial: wound care and oral antibiotics. Deep within 3-4 weeks: washout with component retention. Late deep: two-stage revision with a spacer; involve plastics for flap coverage
- Incidence
- Extensor lag over 20 degrees in 5-10%; complete rupture 1-3%
- Prevention
- Meticulous sleeve repair through bone tunnels with heavy non-absorbable suture; protect for 6 weeks
- Management
- Partial: structured rehabilitation. Complete and early (within 6 weeks): surgical repair. Late: reconstruction with fascia lata or Achilles allograft
- Incidence
- 3-5% at 10 years requiring revision; higher in young or active patients
- Prevention
- Activity restriction; avoid impact; modern thicker polyethylene; regular X-ray follow-up
- Management
- Isolated bushing exchange if bone stock is preserved and components well-fixed. Metal-on-metal contact: urgent revision to prevent component damage
Deep periprosthetic joint infection follows the established algorithm: two-stage revision (component removal, thorough debridement, antibiotic spacer, 6 weeks of IV antibiotics, then re-implantation) is the gold standard; single-stage revision is reserved for a low-virulence organism, no sinus tract and good bone stock (rare at the elbow); resection arthroplasty (a flail elbow) is a salvage option in the elderly low-demand patient and can be surprisingly functional; arthrodesis is technically demanding and rarely chosen. Revision TER principles. Image with CT pre-operatively to assess bone stock; use long-stemmed components to bypass stress risers and old cement; structural allograft for columnar defects; consider custom or tumour-type implants for severe bone loss. Counsel extensively — revision carries a 30-40 percent complication rate. Follow-up. Wound review and X-rays at 2 weeks; ROM, triceps strength and X-rays at 6 weeks; MEPS and cement-interface X-rays at 3 months, 6 months and 1 year; then annual AP and lateral X-rays to watch for migration, cement-mantle fracture, periprosthetic lucency, bushing wear (a widening gap between the linked components) and periprosthetic fracture. CT if loosening is suspected or revision is planned.
Viva & Exam Focus
RULERULE — indications for total elbow replacement
LINKLINK — choosing linked versus unlinked
Every structure here can be injured during a TER, and each is fair game in the viva. The ulnar nerve is the most commonly hit — anterior transposition is mandatory. Also protect the medial antebrachial cutaneous nerve, the radial nerve, the brachial artery and the triceps mechanism itself.
Posterior to the medial epicondyle in the cubital tunnel, then between the heads of FCU. At risk from traction, compression by prosthetic bulk, or scar entrapment. Prevent by identifying and anteriorly transposing it at the start and protecting it with a vessel loop. Palsy in 2-5 percent causes clawing of the ring and little fingers.
Crosses the lateral intermuscular septum and passes anterior to the lateral epicondyle into the radial tunnel. At risk in aggressive anterior-capsule release, lateral retraction, or burring near the radial head. Stay posterior to the lateral epicondyle and avoid blunt retractors anterolaterally. Injury causes wrist drop.
Passes through the antecubital fossa anterior to the elbow joint, medial to the biceps tendon, bifurcating into the radial and ulnar arteries at the neck of the radius. At risk in anterior-capsule release, aggressive retraction, or saw cuts. Avoid anterior retractors beyond the capsule and control the anterior dissection meticulously.
A superficial sensory nerve that pierces the deep fascia proximal to the medial epicondyle and crosses anterior to it in the superficial fat. At risk at the skin incision, superficial dissection and retraction. Identify early and protect with gentle skin-hook retraction. Injury causes medial-forearm dysaesthesia and a painful neuroma.
The entire triceps-on approach depends on a secure periosteal-sleeve repair. Avulsion from the olecranon causes permanent extensor lag and functional failure. Reflect the sleeve sharply off the olecranon tip, reattach through bone tunnels with heavy non-absorbable suture (Krackow or Mason-Allen), and protect the repair for 6 weeks.
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“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. She is on methotrexate and etanercept. How do you manage her?”
“A 47-year-old male construction worker sustains a comminuted distal humerus fracture. CT shows a three-part intra-articular fracture with poor bone quality (DEXA T-score minus 2.8). He is otherwise fit. Discuss your management including the evidence for TER versus ORIF.”
“A patient returns 2 weeks after a total elbow replacement with wound breakdown over the posteromedial elbow — a 1 cm area of superficial skin loss with yellowish exudate. The elbow is warm but the patient is systemically well. How do you manage this?”
Indications (RULE)
- Rheumatoid arthritis (most common; Larsen 3-5)
- Unreconstructable comminuted distal humerus fracture in the elderly (McKee 2008 RCT; Cobb and Morrey 1997)
- Long-standing post-traumatic arthritis
- End-stage primary OA (rare)
Contraindications
- Absolute: active infection, non-functional deltoid or biceps, young patient unwilling to accept restrictions, insufficient bone stock
- Relative: prior osteomyelitis, neuropathic joint, young high-demand (under 50), BMI over 40
Implant choice (LINK)
- Linked (Coonrad-Morrey) for instability, RA, tumour, revision
- Unlinked (Kudo, Souter) needs intact ligaments and normal bone
- 7-8 degrees of laxity reduces cement-interface stress
- Register data: unlinked revision risk 1.9 times that of linked
The exposure — Bryan-Morrey
- Posterior midline incision, curve medially at the olecranon tip
- Ulnar nerve identified and anteriorly transposed FIRST
- Continuous periosteal sleeve medial to lateral, includes the triceps insertion and anconeus
- Repair through bone tunnels (Krackow or Mason-Allen), protect for 6 weeks
Cement & components
- Third-generation cement: plug, lavage, retrograde pressurisation, 2-3 mm mantle
- Link the components before the cement sets
- Target 0-130 degrees flexion, full pronation-supination
- Remove all posterior cement before it hardens
Danger zones
- Ulnar nerve (most common injury; transposition mandatory)
- Medial antebrachial cutaneous nerve (painful neuroma)
- Radial nerve (wrist drop)
- Brachial artery (anterior); triceps sleeve (avulsion)
Complications
- Aseptic loosening 10-15% at 10 years (most common long-term)
- Ulnar nerve palsy 2-5% (usually recovers by 3-6 months)
- Wound or deep infection 3-7%
- Triceps rupture 1-3%; bushing wear 3-5% at 10 years; periprosthetic fracture 3-5%
Lifetime restriction
- Less than 5 kg single-lift for life
- Less than 1 kg repetitive for life
- No racquet sports, golf, contact sports or heavy manual work
- Young patients (under 55) who cannot accept this are not candidates
Revision principles
- 30-40% complication rate — counsel extensively
- CT pre-operatively for bone stock
- Long stems to bypass stress risers; structural allograft for columns
- Two-stage revision for infection; resection arthroplasty as salvage
Background & Evidence
Outcome scoring — Mayo Elbow Performance Score (MEPS). MEPS is the gold-standard outcome measure for TER and underpins every major published series. It scores four domains out of 100: pain (45 points, the largest domain), range of motion (20 points), stability (10 points) and function across six activities (25 points).
- Rating
- Excellent
- Rating
- Good
- Rating
- Fair
- Rating
- Poor
Radiographic staging — the Larsen classification. Larsen grades radiographic rheumatoid destruction on a 1-5 scale; grades 3-5 (moderate-to-severe articular destruction) are the radiographic threshold that brings a rheumatoid elbow into surgical consideration for TER. Disease begins with synovitis-driven cartilage and bone erosion around the ulnohumeral and radiocapitellar joints, progressing to joint-space loss, cysts, erosion and eventual instability and deformity (often valgus in RA). Epidemiology. Rheumatoid arthritis involves the elbow in a substantial proportion of patients over the disease course, and TER for RA is performed worldwide; RA remains the most common indication. Distal humerus fractures in the elderly are increasingly recognised as a TER indication as the population ages. Post-traumatic and primary-OA indications cluster in younger and older patients respectively, and both are smaller cohorts with inferior survivorship. Implant survival and the linked-versus-unlinked evidence. The linked Coonrad-Morrey prosthesis carries the most published long-term data. The seminal RA series (Morrey and Adams 1992) established efficacy and survivorship, and the 10-15 year follow-up (Gill and Morrey 1998) reported 92.4 percent implant survival with 86 percent good or excellent results. The post-traumatic cohort fares worse: Throckmorton 2010 found 75 percent of failures occurred in patients under 60, with 15-year survival of only 70 percent. The large register-linked Plaschke 2014 series (324 procedures) reported 5-year survival of 90 percent and 10-year survival of 81 percent, and a relative risk of revision of 1.9 for unlinked versus linked designs — the quantitative basis for preferring linked implants in most contemporary practice. No large RCT compares the two designs head to head; well-selected unlinked implants give similar functional outcomes but a higher instability risk.
References
ORIF versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients (multicentre RCT)
- 42 patients over 65 with OTA 13C fractures randomised; 40 analysed (15 ORIF, 25 TER on-treatment)
- 5 of 21 patients randomised to ORIF were converted to TER intra-operatively because stable fixation was unachievable
- TER gave significantly higher Mayo Elbow Performance Scores at 3, 6, 12 and 24 months (86 versus 73 at 2 years)
- Reoperation rate 12% (TER) versus 27% (ORIF) — not statistically significant; TER operative time about 32 minutes shorter
Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients
- Retrospective series of 20 patients (21 elbows), mean age 72 years, treated with primary TER for acute distal humeral fracture
- 15 excellent and 5 good results by Mayo Elbow Performance Score; mean flexion arc 25 to 130 degrees
- Only one revision (fractured ulnar component after a fall); no radiographic loosening at follow-up
- Authors explicitly state TER is NOT an alternative to osteosynthesis in younger patients
The Coonrad-Morrey total elbow arthroplasty in rheumatoid arthritis — a ten to fifteen-year follow-up
- 78 elbows in 69 RA patients followed up to 10-15 years after Coonrad-Morrey linked semiconstrained TER
- 92.4% implant survival; 86% good or excellent and 14% fair or poor by Mayo Elbow Performance Score
- 97% of elbows were pain-free or only mildly painful; mean flexion arc 28 to 131 degrees
- Complications in 14% (triceps avulsion, infection, ulnar fracture); 7% of bushings completely worn
Failure patterns after linked semiconstrained total elbow arthroplasty for posttraumatic arthritis
- 85 semiconstrained TERs for post-traumatic arthritis; 19% of primary implants failed at mean 9-year follow-up
- 15-year survival 70% with revision or resection as the end point — markedly worse than RA cohorts
- 75% of failures occurred in patients under 60 years of age (p = 0.03)
- Early failure most often infection; intermediate failure typically bushing wear; late failure loosening or fracture
Implant survival after total elbow arthroplasty — a retrospective study of 324 procedures (1980-2008)
- 324 primary TER procedures in 234 patients (eastern Denmark), mean follow-up 8.7 years, register-linked
- Overall 5-year survival 90% and 10-year survival 81%
- Unlinked designs carried a relative risk of revision of 1.9 versus linked designs
- Fracture sequelae as an indication carried a relative risk of revision of 1.9
Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow
Foundational study of the Coonrad-Morrey implant in rheumatoid arthritis, establishing its efficacy and the survivorship data that subsequent long-term series built on.
Long-term results of the GSB III elbow arthroplasty
Long-term European data on a semiconstrained TER in inflammatory arthritis, demonstrating survivorship comparable to the Coonrad-Morrey.
Semiconstrained total elbow arthroplasty for ankylosed and stiff elbows
Extended TER indications to the stiff or ankylosed elbow, with good functional outcomes.
Extensive posterior exposure of the elbow — a triceps-sparing approach
The original description of the Bryan-Morrey triceps-on approach — the foundational technical paper for the exposure used throughout this guide.
Linked total elbow arthroplasty as salvage for distal humeral nonunion
Evidence for TER as a salvage procedure after failed ORIF of distal humerus fractures presenting as nonunion.
Semiconstrained primary and revision total elbow arthroplasty with the Coonrad-Morrey prosthesis
Comparative analysis of primary versus revision TER outcomes with the linked semiconstrained implant.