SURGICAL TECHNIQUE

Total Elbow Arthroplasty: Surgical Technique

James B. Bennett, MD, Thomas L. Mehlhoff, MD

Implant arthroplasty about the elbow using custom metal components for the distal humerus
and proximal ulna was developed in the 1960s. Before this time, the only salvage procedures
available for destructive joint disease about the elbow were resection arthroplasty, fascial
interposition arthroplasty, or elbow arthrodesis. Today, many total elbow arthroplasty
designs are available and used throughout the world. The Coonrad-Morrey total elbow
prosthesis (Zimmer, Warsaw, IN) is the most widely used implant for elbow arthroplasty in
the United States and has been chosen for discussion in this surgical technique article. (J
Hand Surg 2009;34A:933–939. Copyright © 2009 by the American Society for Surgery of
the Hand. All rights reserved.)
Key words Arthritis, arthroplasty, elbow, surgical technique.

Surgical Technique
began in 1972 with C-ring locking device of the Coonrad-Morrey implant

T
OTAL ELBOW ARTHROPLASTY
the introduction of the Dee prosthesis.1 This (Zimmer, Warsaw, IN) has been replaced with an axis
implant was a constrained articulated prosthesis pin locking device to provide a more secure assembly
requiring methyl methacrylate cement and marked bone of the components.
resection. A high failure rate from loosening led to the Newer designs and surgical techniques have notably
development of semiconstrained and nonconstrained decreased the earlier high complication rate for total
prosthetic implants to reduce bone resection and dis- elbow arthroplasty. Complication rates have dropped
tribute force about the implant to reduce loosening. Dr. from 50% to an acceptable 10% in most series. Reports
Ralph Coonrad introduced a total elbow arthroplasty of total elbow arthroplasty in rheumatoid arthritis pa-
system requiring less bone resection and less biome- tients have shown a 92% survival rate at 10 years after
chanical alteration of the elbow joint than did the Dee replacement.
prosthesis.2 The Coonrad design was further modified
INDICATIONS
at the Mayo Clinic in 1978 under the direction of Dr.
Bernard Morrey. The implant was a semiconstrained The goal of total elbow arthroplasty is to decrease pain
device that would permit 7° to 10° of hinged laxity, and to restore a reasonable arc of motion to the elbow.
corresponding with the normal elbow. In addition, an The primary indication for total elbow arthroplasty is in
anterior flange was added to the humeral component for the rheumatoid arthritis patient, who is preferably 65
fixation with a bone graft to improve anteroposterior years or older with a low level of activity. Relative
stress forces and torsional rotation to increase the sta- indications for total elbow arthroplasty now include
bility and longevity of the implant. Most recently, the patients with osteoarthritis and traumatic arthritis as
well, as greater experience has been accumulated.3,4
Total elbow arthroplasty is also indicated for the acute
From the Baylor College of Medicine, Houston, TX; University of Texas Medical School at Houston,
Houston, TX; and the Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX. treatment of highly comminuted fractures of the distal
The authors thank Mike de la Flor for the illustrations and Daniel P. O’Connor and the Joe W. King humerus in the older patient, where open reduction and
Orthopedic Institute for assistance with the manuscript. internal fixation may not be possible.5 Finally, total
Received for publication December 11, 2008; accepted in revised form February 16, 2009. elbow arthroplasty may be indicated for reconstruction
No benefits in any form have been received or will be received related directly or indirectly to the of bone loss in tumor cases, often requiring a custom
subject of this article. elbow implant.
Corresponding author: James B. Bennett, MD, Fondren Orthopedic Group, 7401 S. Main Street,
Houston, TX 77030-4509; e-mail: [email protected]. CONTRAINDICATIONS
0363-5023/09/34A05-0023$36.00/0 Absolute contraindications include active infection,
doi:10.1016/j.jhsa.2009.02.021
open wound with skin and soft tissue defect, and neu-

©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 933

 934 TOTAL ELBOW ARTHROPLASTY

romuscular paralysis. Relative contraindications in- The elbow joint is then exposed with a triceps split-
clude the noncompliant patient, the heavy laborer, mas- ting or a Bryan-Morrey triceps reflecting approach. The
sive bone loss, or a functional, nonpainful arthrodesis. triceps tendon is incised longitudinally. The attachment
Every patient who has total elbow arthroplasty must be of the tendon to the proximal ulna is carefully reflected
willing to accept a lifetime 5-lb lifting restriction for the from the medial and lateral aspects of the ulna and kept
extremity. in continuity with the forearm fascia extending to the
proximal ulna. Dissection then continues onto the epi-
SURGICAL ANATOMY condyles, releasing the lateral collateral ligament and
A variety of surgical approaches have been de- then the medial collateral ligament from their distal
scribed to expose the elbow joint for total elbow humerus attachments. Finally, the anterior capsule is
arthroplasty. A longitudinal posterior incision released from the distal humerus to fully expose the
through the skin with subcutaneous tissue flaps is elbow joint and release any flexion contracture. Dissec-
most often favored to avoid skin necrosis and tion must stay strictly on the anterior distal humerus to
injury to the cutaneous nerves. Knowledge of the avoid injury to the anterior neurovascular structures.
neurovascular anatomy is essential to avoid nerve More proximal exposure of the humerus for revision
injury, especially to the ulnar nerve. The key to cases or allograft struts will require identification and
Surgical Technique

exposure centers on the triceps tendon and the protection of the radial nerve in the upper arm as well.
olecranon. Currently favored exposures include After release of the soft tissues, the elbow joint can be
the triceps splitting approach, leaving the triceps in easily dislocated, allowing for bone preparation. Radial
continuity with the retinaculum over the proximal head resection may be performed to increase or im-
ulna, or the triceps “on” approach using lateral and prove exposure.
medial fascial incisions to expose the elbow joint The intramedullary canal size of the ulna limits the
for arthroplasty without detaching the triceps. size of the implant more often than does the humeral
Small intramedullary canals due to rheumatoid ar- canal. For this reason, we recommend preparation of
thritis or malalignment due to previous trauma the ulna first. The olecranon tip is removed with the saw
present surgical challenges, requiring proper pre- to improve straight-line access to the canal. A 4.0-mm
operative evaluation and preparation. burr on a long handle is used to penetrate the subchon-
dral bone of the coronoid and expose the canal. The
SURGICAL TECHNIQUE ulnar canal is identified by inserting progressively
Surgery is performed under general anesthesia with an larger curettes or awls. The pilot rasp is then inserted by
optional brachial plexus block catheter positioned in the hand followed by light hammer taps on the rasp handle.
preoperative holding area. The patient is placed supine Proximal bone may need further removal with the burr
on the operating table with a rolled sheet or sandbag to allow proper seating of the rasp. Orientation of the
under the shoulder of the elbow being operated on. The ulnar rasp handle is perpendicular to the flat plane of the
arm is draped free and placed across the chest. It is posterior olecranon. The posterior cortex is more vul-
important that the elbow can be flexed fully during the nerable to penetration than is the anterior cortex during
surgical procedure, especially for preparation of the preparation. Great care should be taken to avoid pene-
ulnar canal. The patient receives an appropriate intra- tration of the dorsal cortex of the ulna at the tip of the
venous antibiotic before the skin incision. A straight rasp. The starter rasp is then used to enlarge the in-
longitudinal incision is placed over the posterior aspect tramedullary canal, followed by the small and regular
of the elbow. The skin incision does not need to curve rasp, if indicated. The correct trial ulnar component is
around the olecranon tip. Full-thickness subcutaneous inserted. The center ring of the ulnar component should
flaps are elevated off the fascia of the triceps. With replicate the normal anatomic axis of the greater sig-
extensive elevation, the flaps will retract back without moid notch. If not, further preparation of the bone
the need for large retractors. should be performed until properly seated.
The ulnar nerve is identified in the upper arm and Preparation of the humerus begins by resecting disks
then decompressed through the cubital tunnel by releas- of bone from the midportion of the trochlea as a rough
ing the fascia in a proximal to a distal direction. If cut. A series of disks is removed, one of which will fit
necessary, the ulnar nerve can be mobilized for anterior under the anterior flange as a bone graft. The intramed-
subcutaneous transposition at the end of the procedure. ullary canal of the humerus is then identified with a
Bipolar electrocautery and loupe magnification increase curette or awl followed by the long-handled burr. The
the safety for surgery about the ulnar nerve. T-handled humeral alignment guide is then placed into

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Surgical Technique
FIGURE 1: A Illustration and B intraoperative photograph for positioning the humeral cutting guide.

the humeral canal, sounding the sides of the canal with with light hammer taps. The regular humeral rasp is
an up-and-down motion. After removing the T-handle, then used if indicated.
the alignment guide is left in place in the humeral canal The trial ulnar and humeral components are inserted,
while the cutting guide is applied. This guide is marked held with a provisional cylinder axis pin. Flexion and
right and left to correspond with the right and left extension of the elbow is assessed. If flexion is limited,
capitellum. The side-arm to the radial side of the hu- the anterior flange may be hitting soft tissue or a prom-
meral cutting guide is locked into place on the capitel- inent coronoid. Reflection of soft tissue or shaving the
lum. Rotational orientation of the humeral cutting guide prominent coronoid with a saw will improve flexion.
should be parallel to the plane of the medial and lateral Likewise, if extension of the elbow is limited, further
humeral columns (Fig. 1). The central humerus is then capsular release or deeper insertion of the humeral
removed with a power saw using the guide as a cutting component may be required. Olecranon tip or olecranon
block. The box cut should be slightly larger than the impingement may also be removed.
implant to avoid splitting of the condyles during im- Humeral and ulnar components are available in ex-
plant insertion. The condyles can be at risk for fracture trasmall, small, and regular sizes, with varying stem
if the bone is overcut at the corners of the cutting jig. lengths. The humeral component is available in 4-inch,
The intramedullary humeral canal is then prepared with 6-inch, and 8-inch stems. The ulnar stems are available
the starting rasp, followed by the small humeral rasp in standard and extralong lengths. Varying sizes of

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 936 TOTAL ELBOW ARTHROPLASTY

humerus until fully seated, locking the anterior bone

graft beneath the flange against the anterior humeral
cortex. Again, excess cement is removed. The elbow is
then held in extension until the cement has hardened.
Premature flexion of the elbow while the cement is soft
may result in pistoning of the ulnar or humeral compo-
nent and cement loosening (Fig. 3).
Intraoperative x-rays are then taken in both antero-
posterior and lateral views to ascertain position for the
implant and to exclude any problems, such as cortex
perforation or periprosthetic fracture. If a bone defect is
detected, bone grafting, plating, or allograft strut may
need to be considered.
Reattachment of the triceps is critical to functional
recovery. The triceps is reattached to the proximal ulna
with large nonabsorbable sutures through drill holes in
Surgical Technique

bone (Fig. 4). The longitudinal component of the triceps

FIGURE 2: Illustration for placement of the axis locking pins. exposure is repaired with side-to-side sutures. The tour-
niquet is released. Pulsed lavage may be used with or
without antibiotics. The wound is closed over a Hemo-
humeral and ulna components are matched at the axis vac drain (BARD, Covington, GA) in standard fashion.
pin coupling device so that an extrasmall ulna may The collateral ligaments do not need specific repair due
articulate with a small or standard humeral component. to the semiconstrained design of the implant. Any re-
Standard cement techniques are used with or without sidual impingement of the ulna on the distal humerus in
antibiotics, based on the surgeon’s preference. Cement extension should be addressed with bone removal if
restrictors, bone plug, or even gel foam can be placed needed. A prominent medial epicondyle might be
into the humerus to improve cement pressure and limit smoothed with the saw as well. The decompressed
cement into the proximal humerus. The actual implants ulnar nerve may be left in situ or anterior transposed
are placed into the ulna and then the humerus to ensure subcutaneously if indicated. The subcutaneous tissue is
good fit before cementing and connecting. At this time, approximated over the deeper structures and the skin
the anterior flange bone graft is selected from the bone well-aligned with staples for a strong, well-sealed clo-
disks previously cut from the trochlea. The anterior sure. Sterile dressings are applied, followed by an an-
humeral cortex is rasped or burred to encourage bone terior and/or posterior fiberglass splint with the elbow in
graft healing once graft position is determined. 30° to full extension. The arm is elevated postopera-
The implants may be inserted and cemented sepa- tively during hospitalization.
rately or simultaneously in conjunction with the locking
axis pin mechanism. The cement is placed into the REHABILITATION
humerus in a viscous state with the cement gun, fol- The patient is admitted to the hospital for appropriate
lowed by pressure packing. Cement is then inserted into pain and medical management. Rheumatoid arthritis
the ulna canal. Extra cement is placed at the tip of the patients often stay for 2 to 3 days, given their limited
ulnar component. The ulnar component is then seated. mobility. The Hemovac drain is monitored for 24 to 36
The excess cement is removed from the ulna. Cement is hours. Pain is controlled with a brachial plexus block
then placed on the tip of the humeral component. The catheter, followed by oral medication. Hand and shoul-
humeral component is partially seated until the anterior der function is encouraged immediately or as soon as
flange grasps the anterior bone graft. The ulnar compo- the block has dissipated.
nent is then aligned with the humeral component (Fig. The wound is allowed to heal before initiating elbow
2). The axis locking pins are then placed and snapped range of motion. At 7 to 10 days, the postsurgical splint
together. The hollow outer axis pin is coupled with the and dressings are removed. An Orthoplast posterior
solid internal axis pin across the articulated humeral and extension splint (Johnson & Johnson, Langhorne, PA)
ulna components with a click at engagement. The driver is fabricated to allow for gentle active range of motion
is then positioned on the humeral component, and a but no triceps muscle resistance. At 2 weeks, the skin
mallet is used to drive the humeral component into the staples are removed as dictated by the condition of the

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Surgical Technique
FIGURE 3: A Illustration and B intraoperative photograph of seating of the implant showing the anterior bone graft locked beneath
the flange.

FIGURE 4: A–C Illustration and D intraoperative photograph of reattachment of the triceps to the proximal ulna.

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 938 TOTAL ELBOW ARTHROPLASTY
Surgical Technique

FIGURE 5: A Preoperative radiograph showing periprosthetic fracture. B Postoperative radiograph showing cortical strut allografts
and unicortical locking plate.

skin and soft tissues. Range of motion is progressed as tibiotic in the cement for even primary cases. Pre-
a home program, emphasizing extension and flexion. A operative skin preparation with hexachlorophene
hinge brace may be used to support the elbow until the soap (pHisoHex; Sanofi-Aventis, Bridgewater, NJ)
flexor and extensor origins have healed to the condyles. for 3 days or 1 week before surgery is recom-
The patient is advised not to lift more than 1 lb during mended.
the first 3 months after surgery and will observe a 5-lb ● During preparation of the ulna, continue to work
permanent lifetime lifting restriction for the extremity. the rasp parallel to the dorsal cortex to avoid
Appropriate x-rays are performed at 3 months, 6 malalignment or posterior bone penetration at the
months, and 1 year postoperatively to evaluate for im- tip of the implant.
plant position, radiolucent lines, or periprosthetic ● The extrasmall ulnar component is available in a
changes in the bone. Our patients are reminded to longer length and can be cut with a bolt cutter if
consider antibiotic prophylaxis for dental, gastrointesti- necessary for proper length fit.
nal, or urologic procedures. ● The humeral condyles can be sacrificed if fractured
or nonunited. The humerus can be shortened to
PEARLS AND PITFALLS achieve full extension if necessary, especially in
● Rheumatoid elbows, especially in juvenile rheu- posttraumatic situations.
matoid arthritis patients, may have very small ul- ● The anterior bow of the humerus should be re-
nar canals that will limit implant size, often requir- spected if a long-stem humeral implant is being
ing the extrasmall component. Be prepared for used. The plate bender may be necessary to give a
intramedullary canal problems that might result slight contour to a long stem to accommodate any
from posttraumatic changes as well. anterior humeral bow.
● Rheumatoid arthritis patients on anti–tumor necro- ● Trial fit the actual components before cementing.
sis factor drugs such as adalimumab (Humira; Ab- A slower-setting cement may be helpful to insert
bott Laboratories, North Chicago, IL), infliximab and seat both components simultaneously.
(Remicade; Centocor, Inc., Malvern, PA), and et- ● The Achilles’ tendon allograft is used for the sal-
anercerpt (Enbrel; Amgen, Inc., Thousand Oaks, vage of triceps rupture or insufficiency.
CA) are at higher risk for infection, including late ● Periprosthetic fractures with a well-fixed compo-
infection. Consider vancomycin or tobramycin an- nent may require cortical allograft struts and band-

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 TOTAL ELBOW ARTHROPLASTY 939

proper decompression of the ulnar nerve. Triceps insuf-

ficiency can occur acute or late and may require recon-
struction with an Achilles’ tendon allograft. Peripros-
thetic loosening and periprosthetic fracture are known
complications, requiring reconstruction with strut allo-
grafts. Instability of the prosthetic components can be a
problem if the locking pin fails or there is abnormal
polyethylene wear of the bushings. Revision axis pin
and bushings sets are available.9
Total elbow arthroplasty has become a successful
reconstruction for painful destructive arthritis about the
elbow with an acceptable complication rate. Patients
must be willing to accept a lifetime 5-lb lifting restric-
tion for the extremity to ensure longevity and ultimate
satisfactory function for the total elbow replacement
(Fig. 6).

Surgical Technique
REFERENCES
1. Dee R. Total replacement arthroplasty of the elbow for rheumatoid
arthritis. J Bone Joint Surg 1972;54B:88 –95.
2. Coonrad RW. Seven-year follow-up of Coonrad total elbow replace-
ment. IN: Inglis AE, ed. Upper extremity joint replacement (sympo-
sium on total joint replacement of the upper extremity, 1979). St.
Louis: C.V. Mosby Co., 1982:91–99.
3. Antuña SA, Morrey BF, Adams RA, O’Driscoll SW. Ulnohumeral
FIGURE 6: Postoperative A anteroposterior and B lateral arthroplasty for primary degenerative arthritis of the elbow: long-
radiographs for the patient in Figure 1 showing the total elbow term outcome and complications. J Bone Joint Surg 2002;84A:
arthroplasty. 2168 –2173.
4. Cheung EV, Adams R, Morrey BF. Primary osteoarthritis of the
elbow: current treatment options. J Am Acad Orthop Surg 2008;16:
ing for reconstruction.6,7 Periprosthetic fractures 77– 87.
5. Kamineni S, Morrey BF. Distal humeral fractures treated with non-
with a loose component require revision with a custom total elbow replacement. Surgical technique. J Bone Joint
longer stem, as well as cortical allograft struts and Surg 2005;87A(Suppl Pt 1):41–50.
banding. Surgery for a loosened component before 6. Athwal GS, Morrey BF. Revision total elbow arthroplasty for pros-
periprosthetic fracture will require revision of the thetic fractures. J Bone Joint Surg 2006;88A:2017–2026.
7. Sanchez-Sotelo J, O’Driscoll S, Morrey BF. Periprosthetic humeral
component, as well as possible impaction bone graft- fractures after total elbow arthroplasty: treatment with implant revi-
ing for intramedullary bone loss.8 Unicortical locking sion and strut allograft augmentation. J Bone Joint Surg 2002;84A:
plates and screws may also secure fixation (Fig. 5). 1642–1650.
8. Loebenberg MI, Adams R, O’Driscoll SW, Morrey BF. Impaction
COMPLICATIONS grafting in revision total elbow arthroplasty. J Bone Joint Surg 2005;
87A:99 –106.
Acute, subacute, or chronic infection is a primary con- 9. Lee BP, Adams RA, Morrey BF. Polyethylene wear after total elbow
cern. Ulnar neuritis symptoms have been minimal with arthroplasty. J Bone Joint Surg 2005;87A:1080 –1087.

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