Total Elbow Arthroplasty

Total elbow arthroplasty (TEA) replaces the ulnohumeral and radiocapitellar articulations to restore a pain-free, functional arc of motion. It is performed less often than hip or knee arthroplasty because of the elbow's complex biomechanics and higher complication rates, and the same complex anatomy makes the operation technically demanding.

Who. Rheumatoid arthritis has historically been the most common indication, at 60-70% of cases, which is why TEA is more common in women, in whom RA is more prevalent. Post-traumatic arthritis and acute distal humerus fractures are an increasing share.

Indications. The elbow destroyed by arthritis:

• Rheumatoid arthritis - the classic indication, with severe joint destruction
• Primary osteoarthritis - less common, typically with stiffness
• Post-traumatic arthritis - following distal humerus fracture malunion
• Haemophilic arthropathy - severe recurrent haemarthrosis

And the acute or failed fracture:

• Distal humerus fracture in the elderly - comminuted, osteoporotic bone
• Failed ORIF - nonunion or malunion with arthritis
• Unreconstructable fracture - when ORIF is not possible
• Age over 65 with low demand and comminution - better outcomes than ORIF on the Mayo score (the other endpoints are set out under Outcomes)

Contraindications. Some rule TEA out; others weigh against it.

• Absolute - active infection, inadequate soft-tissue coverage, a non-functional upper limb (for example after stroke)
• Relative - young age (under 60), high activity level, prior septic arthritis, severe bone loss without reconstruction options

The joint. The elbow is a trochoginglymoid joint, hinge and pivot combined, made up of three articulations.

Stability. The primary stabilisers are the ulnohumeral articulation, in which the coronoid is critical, the anterior bundle of the medial collateral ligament and the lateral collateral ligament complex (LUCL). The radial head, the capsule and the common flexor and extensor origins are secondary. Loss of the primary stabilisers leads to instability that may require a linked TEA.

The medial collateral ligament. The anterior bundle is the most important part: it arises from the medial epicondyle and inserts on the sublime tubercle of the coronoid. The posterior bundle tightens in flexion, and the transverse ligament contributes little.

The lateral collateral ligament complex. It comprises the radial collateral ligament, the annular ligament, which stabilises the proximal radioulnar joint, and the lateral ulnar collateral ligament. The LUCL is the most important of the three and prevents posterolateral rotatory instability.

The ulnar nerve. It passes posterior to the medial epicondyle in the cubital tunnel, between the epicondyle and the olecranon, covered by Osborne's (arcuate) ligament. It is at risk during the medial approach and must be identified early, protected and often transposed anteriorly.

The triceps. Its three heads, the long head from the scapula and the lateral and deep medial heads from the humerus, insert on the olecranon through a common tendon. It is critical for elbow extension and function, triceps insufficiency causes significant functional limitation, and preservation or secure repair of the tendon is essential to the success of a TEA.

Implant DesignFixation Method

Implants are classified by constraint, that is, by what provides their stability.

Linked (semi-constrained)

Mechanism

Sloppy hinge with 7-10 degrees varus-valgus

Indications

Bone loss, instability, RA, revision

Key Features

Coonrad-Morrey, Discovery Elbow

Unlinked (resurfacing)

Mechanism

Ball and socket, relies on soft tissues

Indications

Primary OA, intact ligaments

Key Features

Kudo, Capitellocondylar

Convertible

Mechanism

Can switch between linked and unlinked

Indications

Intraoperative flexibility

Key Features

Latitude, Nexel

Hemiarthroplasty

Mechanism

Distal humerus replacement only

Indications

Acute fracture in elderly

Key Features

Stryker Discovery Hemi

Design Type	Mechanism	Indications	Key Features
Linked (semi-constrained)	Sloppy hinge with 7-10 degrees varus-valgus	Bone loss, instability, RA, revision	Coonrad-Morrey, Discovery Elbow
Unlinked (resurfacing)	Ball and socket, relies on soft tissues	Primary OA, intact ligaments	Kudo, Capitellocondylar
Convertible	Can switch between linked and unlinked	Intraoperative flexibility	Latitude, Nexel
Hemiarthroplasty	Distal humerus replacement only	Acute fracture in elderly	Stryker Discovery Hemi

Linked or unlinked. A linked implant is used when the soft tissues are incompetent or bone loss is significant, because the hinge provides the stability the soft tissues cannot. An unlinked implant relies on intact ligaments and soft tissues. The distinction is similar to that between constrained and unconstrained knee arthroplasty.

The sloppy hinge. The linked hinge allows 7-10 degrees of varus-valgus laxity and is not a fully constrained hinge. The laxity transfers stress to the soft tissues rather than concentrating all the force at the bone-cement interface, which reduces the risk of loosening.

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Cemented

Advantages

Immediate stability, reliable fixation

Disadvantages

Cement debris, difficult revision, loosening

Uncemented

Advantages

Bone preservation, easier revision

Disadvantages

Requires good bone stock, subsidence risk

Hybrid

Advantages

Cemented ulna, uncemented humerus

Disadvantages

Common modern approach

Fixation Type	Advantages	Disadvantages
Cemented	Immediate stability, reliable fixation	Cement debris, difficult revision, loosening
Uncemented	Bone preservation, easier revision	Requires good bone stock, subsidence risk
Hybrid	Cemented ulna, uncemented humerus	Common modern approach

Cement. Cemented fixation of the humeral and ulnar components remains the gold standard, particularly in rheumatoid patients with poor bone quality, and modern third-generation cementing techniques have improved longevity.

Cement Technique

Cementing technique is critical. Prepare the canal, place a cement restrictor, insert the cement retrograde under pressure, then insert the implant and pressurise. Avoid voids and laminations: the thickness of the cement mantle matters for durability.

Distal humeral hemiarthroplasty. It replaces only the distal humeral articular surface, the trochlea and capitellum, which then articulates against the native ulna and radial head. The implant table lists it for the acute fracture in the elderly; it is also the examinable alternative for the younger or higher-demand patient in whom both ORIF and TEA are unattractive. Its indication is an isolated, unreconstructable distal humeral articular fracture (or selected AVN or nonunion) in a patient too young or active for the lifelong restrictions of TEA, but in whom stable ORIF is not feasible.

It depends on the elbow around it, and if the columns or ligaments are deficient, a linked TEA is the correct choice instead.

• The medial and lateral columns must be intact or reconstructable: the implant has no cross-column stem fixation and depends on the columns and the ligament origins
• The collateral ligaments must be competent or repairable

What it gains and what it risks. It preserves bone and carries no lifelong weight restriction, which suits the more active patient. The main concern is progressive wear and erosion of the native surfaces it articulates with, the greater sigmoid notch of the ulna and the radial head, along with the technical difficulty of matching native trochlear sizing, and its evidence base is smaller than that for TEA.

History. Pain is diffuse, may radiate to the forearm, is related to activity and, in advanced arthritis, present at rest, with a grinding, mechanical character. It shows as difficulty with activities of daily living: dressing, eating and hygiene. Ask about previous elbow surgery, which affects the approach and the quality of the soft tissues. The associated symptoms:

• Stiffness - loss of extension is common and compromises the functional arc
• Weakness - reduced grip strength, difficulty lifting
• Instability - giving way, recurrent dislocations
• Numbness in the ulnar distribution (ring and little fingers)

Examination. Look for swelling, forearm muscle wasting, rheumatoid nodules, surgical scars and the carrying angle. Measure active motion against the normal: flexion to 145 degrees, extension to 0-5 degrees of hyperextension, pronation 80 and supination 85 degrees. Passive motion may be preserved despite pain. Document the pre-operative arc, the reference against which the result will be compared, and test triceps and forearm muscle strength.

The rheumatoid patient as a whole. The elbow is one joint in a systemic disease:

• Cervical spine - atlantoaxial instability; flexion-extension radiographs if suspected
• Other joints - hip, knee and shoulder involvement may affect priorities
• Medications - DMARDs and biologics may need adjustment peri-operatively
• Skin - rheumatoid nodules and fragile skin at the surgical site

Radiographs. AP and lateral elbow radiographs are the essential first-line imaging. They show joint space, bone quality and deformity, allow the carrying angle and alignment to be measured, show loose bodies and osteophytes, and assess the bone stock for implant sizing.

CT adds advanced bony assessment: 3D reconstruction for complex deformity, bone stock for revision, templating for implant selection and any previous hardware. It is also useful in acute fractures.

Differential diagnosis. The cause of the painful arthritic elbow changes the implant, the risk, or whether arthroplasty is needed at all.

Blood tests. They look for infection and measure the patient's fitness to heal:

• ESR and CRP - rule out infection and assess disease activity
• Rheumatoid factor and anti-CCP - confirm the diagnosis of RA
• HbA1c - diabetic control, for infection risk
• Albumin and lymphocyte count - nutritional markers of healing capacity

Choosing the approach. Triceps management is the key differentiating factor between the approaches. The Bryan-Morrey approach is the most commonly used for primary TEA, and triceps-sparing approaches are gaining popularity for faster rehabilitation.

Aseptic loosening. It is the most common long-term mode of failure. The ulnar component loosens more often than the humeral, because the ulna has less bone stock. It presents with pain, decreased motion and radiographic lucency.

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Bushing wear. In a linked implant the bushing is polyethylene, and its wear leads to instability.

Periprosthetic fracture: the Mayo (O'Driscoll) classification. It is based on the location of the fracture relative to the components and incorporates implant fixation and bone stock.

• Type I - condyles or columns. The bone around, but not along, the stem. The components are stable, so these are usually managed non-operatively, or by symptomatic fragment excision.
• Type II - along the stem. The humeral or ulnar shaft alongside a stemmed component, subclassified by bone stock and fixation. Good bone with a well-fixed stem takes ORIF; poor bone or a loose stem needs revision with a longer-stemmed component, with or without strut allograft.
• Type III - beyond the stem tip. A diaphyseal fracture distal or proximal to the tip of the stem. With a well-fixed stem, treat it as a standard diaphyseal fracture (ORIF); with a loose stem, revise.

The governing principle. Whatever the type, the decision hinges on three things: location, implant fixation (loose or well-fixed) and bone stock. A well-fixed stem in good bone is fixed; a loose stem or poor bone stock is revised with a long-stemmed component and bone graft.

The weight restriction. A lifelong limit of 2-5 kg minimises stress on the prosthesis and is critical for TEA longevity; the upper figure is roughly the single lift, and repetitive lifting should be far less. Repetitive or single heavy lifting accelerates bushing wear, component loosening and periprosthetic fracture, and non-compliance leads to early failure.

Counselling. TEA is a semi-permanent solution, and the patient must understand the activity limitations. Education and compliance are essential: discuss the restriction at consent and reinforce it at every follow-up visit.

Function. Pain relief is significant in more than 90% of patients. Range of motion improves, typically to a 30-130 degree arc, the ability to perform activities of daily living improves, and satisfaction is generally high when expectations are managed.

What decides the result. The underlying diagnosis matters, rheumatoid elbows doing better than post-traumatic ones, and so do:

• Patient selection - low demand, and adherence to the weight restriction
• Surgical technique and implant position
• Bone quality and soft-tissue health

Global Epidemiology and Practice Variation:

Total elbow arthroplasty is a low-volume procedure worldwide, typically 1-2% of the volume of hip or knee arthroplasty. Historically rheumatoid arthritis dominated the case mix, but improved disease-modifying and biologic therapy has steadily reduced the rheumatoid burden, and most national series now report a rising proportion of acute distal humeral fractures and post-traumatic arthritis. Linked semiconstrained designs predominate in most high-income health systems, with unlinked resurfacing implants reserved for selected primary osteoarthritis or younger patients with competent soft tissues.

Additional Clinical and Access Considerations:

• Higher body mass index and heavy manual occupation are relative contraindications to weigh in patient selection
• Access to specialised revision elbow surgery may be limited in regional, rural, or remote areas, with onward referral to specialist centres for complex cases
• Where occupational injury or compensation is involved, document occupational demands and activity restrictions thoroughly
• Coordinate peri-operative biologic and DMARD management with rheumatology for inflammatory arthritis patients