The most common indications for total elbow arthroplasty are rheumatoid arthritis or other types of inflammatory arthritis, primary or posttraumatic osteoarthritis, and acute fractures. Recent advances in the medical management of inflammatory joint diseases has resulted in a relative decrease in the numbers of total elbow arthroplasties performed for inflammatory arthritides while there has been a simultaneous increase in the use of elbow arthroplasty to treat primary and posttraumatic conditions, as well as acute fractures. Less common conditions treated with total elbow arthroplasty include osteonecrosis, hemophilic arthropathy, comminuted distal humeral fractures, distal humeral nonunions, and periarticular tumors.

Active infection is an absolute contraindication, as with any other joint arthroplasty. A history of remote infection, an inadequate soft-tissue envelope, a nonfunctional hand, and the unwillingness of a patient to be compliant with long-term postoperative activity restrictions and limitations are considered relative contraindications.

Identification and protection of the ulnar nerve is critical when performing an elbow replacement, as it is at risk throughout the operation. The procedure can be simplified by detaching the triceps from the olecranon to improve exposure for placement of the implant components. However, triceps insufficiency is not uncommon, prompting many surgeons to leave some or all of the triceps attached to the olecranon when possible. The medial collateral ligament (MCL) and lateral collateral ligament (LCL) are typically released to allow access to the joint for proper implant placement. Ligament repair is not required if a linked arthroplasty is performed since the mechanical connection between the humeral and ulnar components prevents instability (Figure 23.1). However, a secure anatomic ligament repair is required when using an unlinked prosthesis due to the risk of postoperative elbow instability. Unlinked arthroplasties are prone to instability because there is no connection between the humeral and ulnar components (Figure 23.2). These implants are typically used in younger patients with good bone and ligamentous integrity with a lack of significant bony deformity. The advantage of an unlinked implant is that there is no dependence on a mechanical hinge that may be prone to wear and mechanical failure. This may allow slightly greater loads to be safely applied through the elbow, provided that the collateral ligaments, radial head, and other soft tissues around the elbow are structurally sound. The potential of unlinked arthroplasty to withstand higher loads is the primary reason that it tends to be used in younger patients with higher functional demands. All implants replace the articulation of the ulnohumeral joint. Some implants include the option to retain or replace the radial head, which
contributes to joint stability if an unlinked arthroplasty is selected. Retaining the native radial head or using a radial head implant theoretically reduces wear of the ulnohumeral bearing, and may improve implant longevity. The use of a radial head implant increases cost and complexity of the procedure, and adds another potential source of implant failure. The role of radial head replacement in total elbow arthroplasty remains controversial.

Unlinked implants have become less popular in recent years with the advent of improved reliability of linked devices.
Many have been withdrawn from the market, and only one is currently available in North America. More recently, convertible implants have been developed that provide the option to link an unstable unlinked device without the need to remove the components. This may increase the use of unlinked devices in younger and more active patients in the future since the salvage of an unstable convertible implant can be quick and reliable. Most total elbow implants currently employed are linked, reducing the risk of postoperative instability and allowing expanded indications for the replacement of the
elbow in the setting of periarticular bone loss and ligament insufficiency.

The surgical technique will depend on the elbow arthroplasty system employed. Elbow arthroplasty is typically performed in the supine position; however, some surgeons prefer using a lateral decubitus option. Patients should receive standard prophylactic intravenous antibiotics. A general or regional anesthetic is employed. A sterile tourniquet is recommended to expand the sterile field and allow proximal extension of the incision if required. A posterior midline incision is placed medial to the tip of the olecranon to prevent injury to longitudinally running cutaneous nerves. To reduce the incidence of flap necrosis, full-thickness flaps are elevated on the deep fascia to optimize skin perfusion. The ulnar nerve should be identified and transposed.

The deep surgical approach to the elbow is at the surgeon’s discretion. In the setting of distal humeral bone loss, a paratricipital approach should be considered as it avoids detachment of the triceps from the olecranon, preserving extension strength and allowing for a more rapid functional recovery. This is particularly useful in patients with comminuted distal humeral fractures, in which adequate access to the proximal ulna can be achieved once the distal humeral bone fragments are removed. The paratricipital approach follows the medial–lateral margins of the triceps. In the setting of elbow stiffness and where distal humeral bone stock is preserved, detachment of the triceps from the olecranon facilitates exposure for preparation and insertion of a total elbow arthroplasty. The triceps can be elevated from the olecranon in a medial–lateral direction (Bryan-Morrey) or from the lateral to medial direction (extended Kocher). Alternatively, a triceps-splitting approach can be employed, in which the triceps is split centrally and elevated both medially and laterally off the proximal ulna. Some surgeons prefer the use of a triceps tongue approach, in which a portion of the triceps is left attached to the olecranon to facilitate later repair. All surgical approaches that detach the triceps from the olecranon allow for improved visualization, thus easier and more accurate ulnar component placement. Detachment of the triceps tendon delays return to function, as resisted extension must be avoided until tendon healing is secure; otherwise, disabling extension weakness can compromise outcome. This is particularly problematic for patients who require lower extremity walking aids such as crutches, a walker, or wheelchair.

More recently, a lateral paraolecranon approach has been described. This is a compromise between a triceps-reflecting and paratricipital approach. Exposure of the proximal ulna is improved without the need to restrict postoperative activities or compromising extension strength. The LCL and MCL are sectioned from the humeral epicondyles and the elbow is dislocated by hyperflexion, allowing the olecranon to move away from the humerus. The anterior capsule is elevated off the humerus to allow for placement of a bone graft behind the anterior flange of the humeral component.

An appropriately sized implant is selected. Bony cuts on the distal humerus, proximal ulna, and proximal radius (if applicable) are made using the supplied instruments, and trial prostheses are inserted (Figure 23.3). The radial head is retained in acute fractures or when there is mild arthritic involvement. A trial reduction is performed to ensure that the implants track correctly. If articular tracking is suboptimal, repositioning of an unlinked implant is needed. An unlinked implant should only be considered in younger patients in the setting of good flexor and extensor mechanisms, adequate collateral ligaments, absence of significant preexisting deformity, and retention or replacement of the radial head. A linked implant should be performed when these prerequisites are not met or the trial unlinked implants are maltracking. A radial head component should not be employed if the radial head cannot be made to articulate congruously with the capitellum throughout motion. Linked implants are recommended in elderly low-demand patients because wear and loosening are less of a concern.

In most cases, the implants are cemented. When possible, a cancellous bone graft is placed between the anterior flange of the humeral component and the humerus. Secure the linkage mechanism if a linked arthroplasty is to be performed. The collateral ligaments are repaired back to the epicondyles and the implant if an unlinked arthroplasty is employed. If the triceps was detached, it is repaired to the olecranon through drill holes using locking nonabsorbable Krackow sutures. The ulnar nerve can be transposed into the subcutaneous tissues anterior to the medial epicondyle. The wound is closed in layers over a closed suction drain.

The elbow is initially immobilized with an anterior splint in near full extension if a linked component is used and at 70° of flexion if an unlinked component is used to avoid posterior wound pressure. The drain is removed 1 day postoperatively. Elbow motion exercises are initiated when soft-tissue healing is secure, typically in 10 to 14 days. Rehabilitation can be initiated within 1 to 2 days of surgery to review edema control and to initiate shoulder, wrist, and digital exercises as outlined later.

Unfortunately, complications remain common following total elbow arthroplasty. Intraoperative complications include cortical perforations, fractures, and nerve injuries. Postoperative complications include delayed wound healing, flap necrosis, infection, and triceps insufficiency. Sensory ulnar neuropathy is a relatively common postoperative finding. Instability can occur with unlinked arthroplasties. Infection, aseptic loosening, polyethylene wear, stem fractures, linkage failure, and periprosthetic fractures occur with longer follow-up.

Although the efficacy of rehabilitation after total elbow arthroplasty has been questioned in the literature, the authors have found therapy beneficial for their patients. The therapist assists
with edema control, fabricates appropriate orthoses, educates patients regarding restrictions, reviews range of motion (ROM) exercises, and implements gentle passive stretching if stiffness occurs.