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Elbow Arthroplasty

Total elbow replacement — indications, implants, and recovery.

165 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview¶

Total elbow arthroplasty (TEA) remains the most definitive functional procedure for patients with end-stage painful arthritis of the elbow [8]. While early results are promising in carefully selected patients [1], long-term outcomes obtained over more than 10 years are approaching those of hip and knee arthroplasty [2]. The continued success of TEA depends on advances in surgical planning, technique, implant design, and materials [3]. Indications have shifted markedly in the past decade to address the sequelae of trauma rather than inflammatory conditions [36], with the range of indications broadening to include acute trauma and osteoarthritis [67]. TEA is recommended for distal humeral fractures when strict inclusion criteria are observed [41] and may be performed in younger patients for whom no other alternatives are available [32]. However, TEA should be considered a last step due to the lack of other options after replacement [153].

Functional improvement is possible when proper indications are satisfied, including patient understanding of risks and ability to comply with postoperative rehabilitation [49]. With careful patient selection, convertible TEA provides good to excellent outcomes and substantial improvements in range of movement [73]. TEA is a reliable treatment for elbows severely affected by rheumatoid arthritis, with recent reports showing decreased prevalence of complications, maintenance of excellent pain relief, and functional restoration [10]. Results in patients with rheumatoid arthritis appear nearly as free of complications as those performed for other indications [153]. Concomitant total wrist and elbow arthroplasty is a viable option for selected patients with ipsilateral degenerative changes, offering benefits such as reduced recovery time, lower costs, and decreased morbidity compared to two-stage procedures [159].

TEA is associated with substantial complication and reoperation rates [9]. Patients undergoing elective TEA have slightly higher complication rates than those undergoing shoulder, hip, or knee arthroplasty [22]. Age at surgery is a risk factor for complications, and the indication for TEA in patients under 60 should be carefully considered [17]. Long-term outcome data for TEA designs remain limited [7], and there is insufficient evidence to identify the best type of elbow implant, with choice determined by surgeons' preference, familiarity, and patients' particular circumstances [19]. Survival rates for the Latitude primary TEA remain low and complication rates remain high, yet are comparable to those of other elbow arplasties [78]. The complication and revision rates for joint replacement surgery for elbow tumours are comparable to other indications for elbow replacement surgery [15]. Lateral resurfacing elbow arthroplasty is a satisfactory alternative to TEA with lower rates of complications and does not require activities to be restricted to the same extent [39].

Anatomy & Pathophysiology¶

Bony Anatomy¶

The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that provide bony stability [103]. The ulnohumeral joint is formed by the trochlea articulating with the ulna within the greater sigmoid notch [103]. This articulation provides highly congruent anatomy through almost 180° of articular contact, with the exception of a bare area in the greater sigmoid notch devoid of cartilage [103]. The trochlea has a 300-degree arc of cartilage [56]. The radiocapitellar joint is formed by the capitellum and the radial head [103]. The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [103]. The proximal radioulnar joint holds the radius in close approximation to the ulna via the annular ligament [103].

The distal humerus consists of medial and lateral columns [55]. The distal humeral articulation is angled 30° from the longitudinal axis of the humerus [103]. The articular surface of the distal humerus is angled 30 degrees anterior to the humeral shaft axis [55]. The medial column diverges from the humeral shaft at a 45-degree angle [56], while the lateral column diverges from the humeral shaft at a 20-degree angle [56]. The axis of rotation of the elbow is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side more distal than the lateral side [103]. The ulna bends approximately 8° medially at 8 cm from the tip of the olecranon [103]. The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [103].

Surgical planning relies on specific anatomical landmarks to identify planes of motion. The posterior humeral cortex 35 mm proximal to the medial epicondyle lies in the coronal plane of elbow movement [45]. The inclination of the posterior cortex of the humerus 35 mm proximal to the medial epicondyle identifies the coronal plane of elbow movement [138]. The plane through the ridge of the greater sigmoid notch of a healthy proximal ulna provides a more reliable anatomical landmark to estimate the position of the elbow flexion-extension axis compared to the posterior surface [186].

Ligamentous Anatomy¶

The medial collateral ligament complex comprises the anterior, posterior, and transverse bundles [55]. The anterior bundle of the medial collateral ligament is the primary restraint to valgus stress within functional elbow range of motion [55]. The posterior bundle of the medial collateral ligament is the primary restraint to valgus stress with the elbow in maximal flexion [55]. Stability in full extension is provided by the medial collateral ligament, joint capsule, and ulnohumeral articulation [55]. The anterior oblique ligament of the medial collateral ligament complex originates on the anterior-inferior edge of the medial epicondyle and inserts on the sublime tubercle of the ulna [121]. The anterior band of the medial collateral ligament is taut in extension, and the posterior band is tight in flexion [121].

The lateral ulnar collateral ligament origin center is 10.7 mm from the lateral epicondyle and its insertion is 3.3 mm from the apex of the supinator crest [101]. The ulnar nerve passes through the cubital tunnel at the medial column of the elbow [56]. The posterior bundle of the medial collateral ligament forms the floor of the cubital tunnel along the course of the ulnar nerve [31].

Biomechanics and Kinematics¶

Normal range of elbow flexion/extension is 0 to 150 degrees [55]. Normal forearm pronosupination is 80 to 85 degrees in each direction [55]. The functional range of motion for the elbow is 30 to 130 degrees flexion/extension and 50 degrees pronosupination [55]. The normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [55]. In full extension, 60% of axial load is transmitted through the radiocapitellar joint [55]. The normal elbow has a range of motion from 0° to 140° from extension to flexion and 75° and 85° in pronation and supination respectively [54]. A functional arc for the elbow is 100° for flexion and extension and forearm rotation [54].

Elbow stability is determined by primary stabilizers (ulnohumeral articulation, medial ulnar collateral ligament, lateral ulnar collateral ligament complex) and secondary stabilizers (radiocapitellar articulation, common flexor tendon, common extensor tendon, joint capsule) [54]. Component alignment, articular configuration, and soft-tissue balance can affect the kinematics of total elbow arthroplasty [37]. No implant replicated the behavior of the human ulnotrochlear joint, with most designs being less constrained than a normal elbow [139]. With optimal total elbow arthroplasty implantation, the general pattern of change of muscle moment arms with elbow flexion resembled that of the intact elbow, but with increased flexor dominance over the extensors with elbow flexion [127]. Shoulder abduction results in a varus moment at the elbow [128]. Muscle forces have an important role in stabilizing the capitellocondylar total elbow [160].

The valgus angulation of available elbow designs is discordant with the mean native valgus angulation, and the valgus laxity of the implants does not cover the variability in the studied population [175]. The kinematics of the elbow deviated increasingly from those of the native joint with a 2 mm to a 4 mm lengthening of the radius [105]. Overstuffing the radial head prosthesis alters joint kinematics and may lead to pain and degenerative changes [169]. Insertion of a correctly sized metallic radial head replacement recreates near normal biomechanics of the forearm with no change in the loading characteristics of the interosseous membrane [147]. The radial head prosthesis mimics the mechanics of the native radial head in terms of mean contact area, mean contact pressure, and peak contact pressure, but different patterns of contact pressure and area curves during elbow flexion-extension were observed [190]. From a biomechanical perspective, the enhancement of elbow stability with a monopolar radial head prosthesis is superior to that with a bipolar design [132]. Loading increases for all malaligned implant positions tested in total elbow arthroplasty [238]. Combinations of internal-external and varus-valgus malrotations that preserve the line of action of the elbow flexors result in lower loads than combinations that do not [238]. Cementing a nonanatomic hinge that may not rely on the native elbow soft tissue support can result in a troubling biomechanical environment [142].

Pathophysiology¶

Osteoarthritis of the elbow is characterized by osteophyte formation, capsular contracture, and loose bodies, often with relative preservation of the joint space [35]. Periarticular hypertrophic osteophytes act as a mechanical block at the end ranges of flexion and extension in elbow osteoarthritis [35]. Osteoarthritis typically involves the radiocapitellar joint articular cartilage preferentially, with relative preservation of the ulnohumeral articular surfaces [35]. Ulnar neuropathy is present in up to 50% of patients with elbow osteoarthritis [35]. If the elbow has less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament is contracted and must be released to restore flexion [31]. The pathoanatomy of valgus extension overload syndrome includes chondrosis, osteophyte development on the posteromedial olecranon and humerus, and loose bodies [65]. Olecranon resection increases valgus angulation and medial collateral ligament strain during valgus stress [65]. Overaggressive olecranon resection may result in valgus instability of the elbow [65].

Dislocations of the elbow occur when loads placed on the structures about the elbow exceed the intrinsic stability provided by the anatomic shape of the joint surfaces and soft-tissue constraints [60]. Posterior dislocations are the most common type of elbow dislocation, resulting from an axial force applied to the extended elbow [60]. Both collateral ligaments are disrupted in posterior elbow dislocations, whether posteromedial or posterolateral [60]. The lateral ulnar collateral ligament injury is the cause of recurrent instability after elbow dislocation [60]. An elbow dislocation and associated fracture of the coronoid process increase the risk of recurrent and chronic instability [60]. When there is greater than 50% loss of the coronoid, fixation is mandatory according to cadaver studies [60]. The "terrible triad" of the elbow consists of elbow dislocation with radial head and coronoid fractures [60]. The most common problems after terrible triad injuries are recurrent and chronic instability, stiffness, posttraumatic arthrosis, and pain [60].

Aseptic loosening is the most prevalent reason for revision of total elbow arthroplasty [94]. Deep infection is the second most prevalent reason for revision of total elbow arthroplasty [94]. Periprosthetic fractures are the third most prevalent reason for revision of total elbow arthroplasty [94]. Periprosthetic fractures occur in 5.4% of total elbow arthroplasties [204]. Intraoperative periprosthetic fractures occur slightly more commonly than postoperative fractures [204]. Humeral condylar fractures are the most common intraoperative periprosthetic fractures [204]. The vast majority of postoperative periprosthetic fractures occur in the setting of preexisting component loosening [204]. Periprosthetic fracture adjacent to a well-fixed implant is exceedingly rare [204]. The radial nerve is highly vulnerable in revision arthroplasty and fracture care due to its intimate relationship with the humeral shaft [213]. Thermal necrosis of the radial nerve can occur from extruded polymethylmethacrylate cement during total elbow arthroplasty [213]. Postoperative nerve injury is a common complication of revision total elbow arthroplasty, affecting approximately one in five cases [28]. The ulnar nerve is most frequently involved in nerve injury following revision total elbow arthroplasty [28].

Classification¶

Copenhagen Classification of Distal Humeral Fractures (CCDHF): This system distinguishes distal humeral fractures that may not be suitable for open reduction and internal fixation (ORIF) and may require treatment with elbow hemiarthroplasty or total elbow arthroplasty [235]. Its primary objective is to identify fractures not amenable to ORIF and indicate the potential need for treatment at a specialized tertiary center where these arthroplasty options are available [235]. The CCDHF was compared for inter- and intra-observer agreement with the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) and the Sheffield classification systems [235].

Radiographic Loosening Grading: Radiographic findings of prosthetic loosening in total elbow arthroplasty are graded into three types based on radiolucent line thickness and interface involvement [82]. Type 0 indicates a radiolucent line less than one millimeter thick and involving less than 50 percent of the interface [82]. Type I indicates a radiolucent line at least one millimeter thick and involving less than 50 percent of the interface [82]. Type II indicates a radiolucent line more than one millimeter thick and involving more than 50 percent of the interface [82].

Mayo Classification: This system categorizes periprosthetic fractures in total elbow arthroplasty based on bone and implant status to guide treatment considerations [237].

Other Considerations: A classification system for elbow osteoarthritis is presented in the literature [5]. A classification of humeral bone loss has been proposed to allow for better planning of primary and revision total elbow arthroplasties [129]. The American Rheumatoid Association classification is used to assess the functional severity of rheumatoid arthritis disease [182], while the American College of Rheumatology criteria are used for the classification of rheumatoid arthritis [242]. The Goldberg classification determines whether radiographic loosening observed at one year is progressive or associated with initial cement mantle quality [230]. The Larsen et al. classification is used to grade elbows in the context of total elbow arthroplasty follow-up [81].

Clinical Presentation¶

History and Symptoms¶

A thorough history and physical examination are invaluable for understanding the disease process and its impact on the patient [225]. The location, quality, context, duration, and severity of elbow pain help focus the physical examination [226]. Determining the symptom trajectory—whether pain is improving, worsening, or constant—is critical when considering intervention [226]. Prior treatments, including surgical interventions and injections, aid in correct diagnosis [226]. For elbow stiffness, the history must include the duration of contracture, initial injury, previous surgeries, trials of splinting or therapy, surgical complications, and the patient’s work and life goals [31].

In primary elbow osteoarthritis, pain is typically noted at the end ranges of motion rather than through the midrange [35]. Night pain is not typical; if present, an inflammatory cause should be considered [35]. Patients typically present with loss of terminal extension and flexion, along with painful catching, clicking, or locking [35]. The degree of disability depends on the patient’s vocation and physical disability [35]. Understanding whether pain occurs throughout the arc or only at terminal limits is of paramount importance [225]. Associated mechanical symptoms, instability, and conditions such as cubital tunnel syndrome must be evaluated to provide optimal management recommendations [225].

Physical Examination¶

The physical examination focuses on functional anatomy, including inspection, palpation, range of motion, strength, stability, and special tests [226]. The examination is guided by the history, which is the most valuable tool for directing the clinical assessment [226]. A working knowledge of pathologic conditions affecting different locations around the elbow is paramount for correct diagnosis [226]. Examination elements are dynamic, and adequate assessment often combines maneuvers to fully elucidate pathology [226].

Inspection: Inspect for prior surgical incisions and joint effusion at the lateral soft spot in patients with elbow osteoarthritis [35]. For elbow stiffness, examine the soft tissue surrounding the elbow for previous skin incisions, grafts, eschar, or infection [31].

Palpation and Neurovascular Assessment: The ulnar nerve is of utmost importance during neurovascular examination due to its anatomic proximity to the elbow [31]. If a history of prior surgical procedures exists, verify if the ulnar nerve has been transposed [31]. An assessment for ulnar nerve subluxation is required, as subluxation is a relative contraindication for arthroscopic procedure secondary to possible iatrogenic nerve injury [31]. Electromyography/nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists [31].

Range of Motion: Active and passive flexion, extension, supination, and pronation should be evaluated using a goniometer for accurate measurement [31]. The contralateral elbow should be examined for comparison [31]. Pain should be assessed during the mid-arc or at the terminal ends of motion [31]. Mid-arc range of motion pain is more common with intrinsic disease and may not improve with contracture release alone [31]. In patients with flexion or extension contractures, the examiner should concentrate on solid or soft end points and pain or crepitus during the arc and at the end points [223]. The upper extremity should be examined from the side with the hand in full supination to adequately assess for contracture [223]. The examiner should record both active and passive values for elbow motion [223]. Any significant difference between active and passive ranges of motion suggests pain or motor dysfunction as the cause [223].

Functional Implications: Loss of full extension is the first motion altered by most pathology and the last to be regained [223]. Forearm rotation is relatively preserved until later in the disease process of elbow osteoarthritis [35]. To perform 90% of required daily activity, 50° of pronation and supination are required [223]. Pronation is the most important function on the dominant side for eating and writing, and loss of pronation is compensated by shoulder abduction [223]. A loss of supination of the nondominant side may significantly hinder personal hygiene needs, accepting objects, and opening door handles [223]. Tasks requiring supination are poorly compensated by shoulder or wrist function [223]. Flexion contractures of less than 45° may have little practical significance, although patients may be concerned about the cosmetic appearance [223]. A careful assessment of any compromised motion at the shoulder or wrist is required, as disability often arises from a combination of factors [223]. Function of the upper extremity (shoulder, wrist, and hand) should be assessed during the physical examination for elbow stiffness [31].

Stability and Special Tests: In a trauma situation, the likelihood of significant joint pathology in the face of normal elbow motion is so small as not to require radiographic analysis [223]. Rupture of the triceps tendon or neurologic conditions should be suspected if there is loss of active extension [223]. Loss of passive extension is a sensitive but nonspecific sign of an intra-articular process [223]. The simple extension test has a sensitivity of 97% and a negative predictive value of 98% [223]. The specificity of the simple extension test is 69%, with a positive predictive value of 63% [223]. The radial head is driven into the capitellum with pronation by the screw-home mechanism [223]. When combined with flexion or extension under a load as in the radiocapitellar load test, reproduction of radiocapitellar pain signals a problem with the joint [223]. Crepitus can be noted with the radiocapitellar load test maneuver [223].

Imaging¶

Plain radiographs should be obtained during the initial workup to evaluate the articular surface and bony anatomy in elbow degenerative conditions [225]. Standard AP and lateral radiographs should be obtained for elbow osteoarthritis [35]. Radiographs for elbow osteoarthritis typically show osteophyte formation at the coronoid process (anterior and medial), coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa [35]. Joint spaces at the ulnohumeral joint are usually preserved in elbow osteoarthritis [35]. Joint spaces at the radiocapitellar joint are mildly narrowed in elbow osteoarthritis [35]. Loose bodies may be evident on radiographs, which typically underestimate the number present [35].

For elbow stiffness, radiographs should always be obtained [31]. AP, lateral, and oblique radiographs are standard, with serial radiography as follow-up when heterotopic ossification is present [31]. The primary bony landmarks for radiographic evaluation include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [31]. CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [31]. Three-dimensional CT is used to check for heterotopic ossification [31]. CT is not necessary when the stiffness is entirely soft-tissue related [31]. If any joint incongruity or abnormal bony anatomy is present, CT is beneficial [31]. CT may be useful for surgical planning in elbow osteoarthritis, allowing a detailed assessment of osteophytes and the presence of loose bodies [35]. CT scans with 3D reconstructions may be useful for evaluating the extent and location of disease and for surgical planning [225].

MRI can be used to evaluate ligaments and tendons, but it is rarely indicated for elbow stiffness [31]. MRI may be useful to evaluate the status of the soft tissues including the medial and lateral collateral ligamentous complexes [225]. Electromyography and nerve conduction studies (EMG/NCS) may be useful to evaluate the degree of nerve compression and contribution to the elbow pain and/or dysfunction [225].

Investigations¶

History and Physical Examination¶

The history for elbow stiffness must document the duration of the contracture, initial injury, previous surgical procedures, trials of splinting, therapy, or injections, surgical complications, and patient work or life demands [31]. Physical examination requires assessment of upper extremity function at the shoulder, wrist, and hand, along with inspection of soft tissues for previous incisions, grafts, eschar, or infection [31]. Range of motion assessment must include active and passive flexion, extension, supination, and pronation using a goniometer, with the contralateral elbow examined for comparison [31]. Pain assessment during range of motion should distinguish between mid-arc pain, which is more common with intrinsic disease, and terminal end pain [31].

The ulnar nerve is of utmost importance in the neurovascular examination due to its anatomic proximity to the elbow and the posterior bundle of the medial collateral ligament forming the floor of the cubital tunnel [31]. Electromyography and nerve conduction velocity studies should be performed if there is any question about neurologic dysfunction [31]. An assessment for ulnar nerve subluxation should be performed, as subluxation is a relative contraindication for arthroscopic procedure due to possible iatrogenic nerve injury [31]. If a history of prior surgical procedures exists, it must be verified if the ulnar nerve has been transposed [31].

Patients with primary elbow osteoarthritis typically present with loss of terminal extension and flexion and painful catching, clicking, or locking [35]. Night pain is not typical for primary elbow osteoarthritis; if present, an inflammatory cause should be considered [35]. Physical examination for primary elbow osteoarthritis includes inspection for prior surgical incisions and joint effusion at the lateral soft spot [35]. Forearm rotation is relatively preserved until later in the disease process of primary elbow osteoarthritis [35]. Ulnar neuropathy is present in up to 50% of patients with primary elbow osteoarthritis [35]. The chosen treatment for distal humerus fracture in older patients must allow at least 100° and preferably 120° of flexion–extension at the elbow [23].

Imaging¶

Plain radiography: Standard radiographs for elbow evaluation include AP, lateral, and oblique views [31]. Plain radiographs remain the hallmark and the best screening test for elbow pathology [54]. Primary bony landmarks on elbow radiographs include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [31]. Radiographs for primary elbow osteoarthritis typically show osteophyte formation at the coronoid process (anterior and medial), coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa [35]. Joint spaces at the ulnohumeral joint are usually preserved in primary elbow osteoarthritis, while those at the radiocapitellar joint are mildly narrowed [35]. Radiographs typically underestimate the number of loose bodies present in primary elbow osteoarthritis [35].

Oblique radiographic views may be useful to identify periarticular fractures in acute elbow dislocation [130]. Plain AP and lateral radiographs of the elbow are necessary to document congruent reduction after acute dislocation [130]. AP, lateral, oblique, and axillary views of the elbow may reveal posteromedial olecranon osteophytes and/or loose bodies in valgus extension overload syndrome [65]. Radiographic evaluations are essential when diagnosing an osteochondritis dissecans lesion of the elbow [131]. Plain radiographs are still most often employed for medial epicondyle fractures, though oblique and axial views have been proposed to improve measurement accuracy of displacement [136]. The radial head arthroplasty diameter can be predicted preoperatively in two-thirds of cases from a simple measurement of the humeral condyle diameter with an appropriate lateral view of a simple radiograph [245]. Pre-operative templating using plain elbow radiographs does not add benefits in pre-operative decision making for total elbow arthroplasty [265].

CT: CT is not necessary when elbow stiffness is entirely soft-tissue related [31]. CT is beneficial if any joint incongruity or abnormal bony anatomy is present [31]. CT may be useful for surgical planning in primary elbow osteoarthritis by allowing a detailed assessment of osteophytes and the presence of loose bodies [35]. CT scan with three-dimensional reconstruction is helpful for preoperative planning of intercondylar fractures [56]. CT is useful to identify associated osseous injury in acute elbow dislocation [130]. With an incongruous reduction of the elbow, CT or MRI should be considered to identify potential incarcerated osteocartilaginous fragments [130]. CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [65].

MRI: MRI is the imaging modality best suited for evaluating soft-tissue structures in the elbow including ligaments, tendons, cartilage, and nerves [123]. Conventional MRI sequences should be obtained in all three planes using T1-weighted and fluid-sensitive sequences (short tau inversion recovery or T2-weighted sequences with fat suppression) [123]. Coronal MRI studies should be obtained along a line connecting the medial and lateral epicondyles, and sagittal studies should be perpendicular to the coronal studies [123]. Magnetic resonance arthrography is particularly beneficial in the evaluation of osteochondral lesions, loose bodies, and ulnar collateral ligament injury in a throwing athlete [123]. MRI may be most helpful in evaluating associated injuries including partial or complete tears of the medial collateral ligament in valgus extension overload syndrome [65]. Important aspects of osteochondritis dissecans lesions may be better seen with MRI [131]. MRI of the elbow and the upper extremity athlete may be employed to identify partial or periosteal sleeve avulsions of the medial epicondyle [136].

MRI units with a 3-Tesla magnetic field strength can generate high signal-to-noise ratios and are more able to show normal anatomy than a 1.5-Tesla unit [123]. Caution is necessary with 3-Tesla imaging because it can show mild signal alterations of tendons, ligaments, and nerves of the elbow that may not be symptomatic [123]. Ligaments and tendons appear anechoic (black) on all MRI imaging sequences [123]. With tissue remodeling or degeneration, the signal increases on all MRI sequences [123]. Tears are diagnosed on MRI by identifying signal in the tissue that brightens to the level of simple fluid, representing focal discontinuity of tendon or ligament fibers [123]. Partial tears on MRI are described by identifying whether the involved pathology occurs at the articular side, intrasubstance, or involves superficial fibers [123]. Both partial-thickness and full-thickness tears on MRI should identify whether failure occurs proximally, mid-substance, or distally [123].

MRI studies in symptomatic youth athletes with Little Leaguer's elbow often show edema at the distal humerus or medial epicondyle apophysis [135]. Preseason MRI abnormalities in youth baseball players were associated with year-round play, private coaching, and loss of shoulder internal rotation [135]. Postseason MRI evaluation of dominant elbows revealed abnormalities in 46% of Little League players [135]. MRI was able to identify the cause of medial elbow pain in 20 (95%) of 21 throwing athletes [244].

Post-arthroplasty Radiographic Surveillance: Heterotopic ossification after total elbow arthroplasty is seen more commonly than previously reported [249]. Serial radiography is used as follow-up when heterotopic ossification is present [31]. Poor ulnar cementation may predict radiological loosening and eventual need for revision in total elbow arthroplasty, but this loosening does not correlate with the patient's clinical outcomes [259]. There is concern about early radiologic loosening of the radial component in Latitude primary total elbow replacement, though this has not resulted in clinical symptoms or implant failure yet [243]. Increased incidence of radiolucent lines around the ulnar stem and bushing wear with longer follow-up is of concern and represents the failure mode for the Coonrad/Morrey total elbow arthroplasty implant [275]. The Discovery elbow replacement demonstrates early clinical results similar to other semi-constrained total elbow replacements, with continued radiological surveillance warranted for humeral lucency [24]. Further follow-up is required to investigate the radiological changes observed in some patients with semiconstrained total elbow arthroplasty for rheumatoid arthritis [274]. In this series of semiconstrained total elbow arthroplasty, 5.3% of the elbows have had a failure of the locking mechanism, which is most likely higher as not all patients have had radiographic follow-up within the last year [267]. The case presented represents distal humeral osteolysis associated with gross and microscopically identified polyethylene debris surrounding a cemented semiconstrained total elbow prosthesis [269]. If a radial head prosthesis is used in complex elbow dislocations, prosthesis oversizing should be avoided as it may contribute to worse outcome with other radiographic abnormalities [266]. At a minimum of three-year follow-up, both cases of revision radiocapitellar arthroplasty by mismatched implant components improved from poor to good and excellent Mayo elbow performance scores with no signs of implant failure on standard radiographs [18]. There is radiographic evidence of the restoration of the humeral and ulnar bone stock in the short term following intramedullary fibular and impaction allografting in revision total elbow arthroplasty [90]. We report good early to mid-term clinical and radiographic outcomes for custom ulna prosthesis use in challenging revision elbow arthroplasty [262]. The overall interobserver reliability of radiographic assessment following press-fit bipolar radial head arthroplasty was poor among experienced elbow surgeons [263].

Treatment¶

Non-Operative¶

Nonsurgical management may provide relief in early stages of elbow arthritis [63]. Treatment of elbow arthritis must be individualized based on etiology, severity, patient age, and functional demands [63, 72]. For primary elbow osteoarthritis, treatment options range from conservative management to open debridement, arthroscopy, and total elbow arthroplasty in selected patients [173]. Surgical options for elbow arthritis range from arthroscopic debridement for pain at motion extremes to total elbow arthroplasty for pain throughout the arc of motion [63].

Operative¶

Indications: The primary indications for total elbow arthroplasty are pain and/or instability [88]. Deformity and dysfunction without pain are not indications for surgery [88]. An unreconstructible distal humeral fracture in an elderly patient is an increasingly common indication [88]. Rheumatoid arthritis with radiographic evidence of joint destruction too far advanced to benefit from radial head excision and synovectomy is generally considered an indication [88]. Elderly patients with end-stage posttraumatic sequelae are acceptable candidates [88]. Bony or fibrous ankylosis with the elbow in a poorly functioning position is an indication for elbow arthroplasty [88]. In patients with rheumatoid arthritis, arthroplasty should be considered only after medical treatment has failed and the disease has advanced to show bony changes [88]. Total elbow arthroplasty is a surgical option for end-stage elbow arthritis with indications expanding from rheumatoid arthritis to osteoarthritis, post-traumatic arthritis, and acute fractures [149]. The range of indications is broadening, with use for acute trauma and osteoarthritis becoming increasingly more common [67]. Indications have changed markedly in the past decade to address the sequelae of trauma rather than inflammatory conditions [36]. Total elbow arthroplasty is an effective treatment for various conditions about the elbow, with the main goal being pain relief [38]. Total elbow arthroplasty can be considered a therapeutic option for flail or grossly unstable elbow articulations [125, 172]. Salvage of supracondylar non-union by means of a total elbow arthroplasty is a technically demanding procedure that should be done only when other therapeutic options are unsatisfactory [163]. Total elbow arthroplasty provided adequate pain relief and good functional restoration when successful for post-traumatic sequelae after proximal ulna or radius fracture and fracture-dislocations [89]. Total elbow arthroplasty is effective in relief of pain and restoring hand function for rheumatoid arthritis of the elbow [48]. Total elbow arthroplasty has become a reliable treatment option for elbows severely affected by rheumatoid arthritis, with recent reports showing decreased prevalence of complications, maintenance of excellent pain relief, and functional restoration [10]. Total elbow arthroplasty provides a successful early outcome for most elderly patients with comminuted distal humerus fractures [29]. Direct comparisons between internal fixation and arthroplasty for selected elderly patients with distal humerus fractures have shown better outcomes with arthroplasty [29]. This retrospective review supports a recommendation for total elbow arthroplasty when strict inclusion criteria are observed for distal humerus fractures [41]. Total elbow arthroplasty performed acutely for distal humerus fractures results in satisfactory outcomes and should be a consideration for patients at high risk of failing ORIF or nonsurgical management [91]. Total elbow arthroplasty for distal humerus fractures provided similar clinical and functional outcomes when performed as a primary procedure or after failed internal fixation [85]. Unlinked, noncongruous elbow arthroplasty can be a successful alternative in the management of acute distal humeral fractures when internal fixation is not a viable option [157]. If excision of the fragments is avoided in a fractured rheumatoid elbow, original or near original anatomy of the elbow joint can be better restored and acceptable outcome obtained with elbow arthroplasty [69]. Elbow hemiarthroplasty is an option for young or active patients with end-stage elbow arthritis or unreconstructable distal humerus fractures in whom alternative procedures have failed [187].

Contraindications and Risk Factors: A history of previous elbow sepsis is an absolute contraindication to prosthetic elbow implant arthroplasty according to Ewald [88]. Coonrad and Morrey considered infection, excessive use of the elbow, ankylosis of the ipsilateral shoulder, and the presence of neurotrophic joints to be contraindications [88]. Extensive bone loss on either side of the joint and poorly functioning flexor and extensor mechanisms are contraindications according to Kudo et al. [88]. The age at surgery is a risk factor for complications, and the indication for total elbow arthroplasty in patients under 60 should be carefully considered [17]. Higher demand, male gender, trauma-related, and young age have consistently been linked to poorer outcomes and higher risk of revision following TEA [87].

Surgical Approach / Technique: The surgical and therapeutic management for total elbow arthroplasty is reviewed, including surgical overview, techniques, stability issues, and a proposed postoperative treatment plan [27]. The review discusses various approaches to total elbow arthroplasty and their reported outcomes to assist surgeons in making an informed choice [12]. The aim of an article on total elbow arthroplasty is to illustrate technique, acknowledging the key technological advancements and evidence-based techniques that have emerged in the last 2 decades [107]. The Van Gorder approach for total elbow arthroplasty is the subject of the largest study evaluating this approach with an average follow-up of 32 months [68]. The author's experience indicates that the triceps split technique is now his preferred method for most total elbow arthroplasty cases [112]. A triceps split approach allows total elbow arthroplasty to be performed without compromise to the triceps insertion and ideal placement of the ulnar component [122]. The triceps fascial tongue exposure provides an excellent view of the joint while causing minimal trauma to the extensor mechanism facilitating tendon healing, and easy intraoperative conversion from fracture fixation to a total elbow arthroplasty if a fracture is not able to be reconstructed [224]. In a case series of 30 total elbow arthroplasties using the triceps fascial tongue exposure, there were no triceps-related failures [224]. The selected approach for elbow hemiarthroplasty should allow sufficient access for articular fragment resection, condyle/collateral ligament repair and humeral instrumentation [208]. A commonly described approach for elbow hemiarthroplasty is via an olecranon osteotomy, which affords good visualization of the distal humeral articular surface but requires fixation with further hardware [208]. Of 39 reported cases of olecranon osteotomy for elbow hemiarthroplasty, 13 patients (33%) required further surgery for problems related to the olecranon osteotomy [208]. The most commonly described approach in the literature for elbow hemiarthroplasty has been the triceps split by Adolfsson’s group in Scandinavia [208]. Twenty-two reported cases used a ‘triceps on’ approach for elbow hemiarthroplasty, which facilitates early-unrestricted range of motion and negates the issues of subcutaneous hardware and triceps failure [208]. As part of the surgical approach for elbow hemiarthroplasty, the ulnar nerve is identified, mobilized and protected but is not routinely transposed, unless it lies in a specific position [208]. Total elbow arthroplasty in the setting of an olecranon fracture can be achieved using the olecranon fragment to achieve superior surgical exposure [215]. The extended olecranon osteotomy for revision total elbow arthroplasty provides reliable, atraumatic access to the ulnar canal, cement mantle, and component for safe extraction of a well-fixed implant [194]. The osteotomy configuration for extended olecranon osteotomy provides a large surface area for bony healing, thus restoring the integrity of the proximal ulna for later cemented reimplantation [194]. An extended deltopectoral approach is used for revision total elbow arthroplasty requiring humeral allograft-prosthetic composites in patients with severely compromised proximal humerus bone stock [212]. The patient is placed supine with the torso angled approximately 60°cephalad in the 'high beach chair' or 'barber chair' position for extended deltopectoral approach revision TEA [212]. No tourniquet is used given the proximal extent of the planned dissection for extended deltopectoral approach revision TEA [212]. The incision for extended deltopectoral approach revision TEA is marked from just lateral to the coracoid process proximally to mid-anterior proximal forearm distally [212]. It is important to carry the distal dissection across and past the elbow flexion.

Implant Selection: Selection of the type of prosthetic implant depends to a great extent on the state of the capsuloligamentous structures around the elbow and the integrity of the musculature and the amount of bone remaining at the elbow joint [88]. Generally, the more bone remaining and the more stable the joint, the more suitable the joint is for replacement with a resurfacing or unconstrained prosthetic implant [88]. More constrained prosthetic designs should be selected for patients with injury to the stabilizing ligaments and capsule of the joint, atrophic musculature, and loss of considerable bone stock [88]. Relative contraindications to the use of an unconstrained resurfacing arthroplasty included excessive bone loss, as in giant rheumatoid cysts, deficiency of the trochlear notch of the ulna, and posttraumatic or degenerative arthritis [88]. Total elbow arthroplasty was initially introduced as a treatment for end-stage inflammatory arthropathy [87]. Initial “fixed-hinge” designs were plagued with failure because the hinges were fully constrained allowing <1 degree of varus–valgus laxity and failed to restore physiologic mechanics to the elbow [87]. Unlinked implants were introduced to better restore normal elbow mechanics and rely on intact capsuloligamentous restraints for stability and function [87]. Unconstrained models promise to dissipate forces through the ligaments and capsule, shielding the cement–bone interface, aiming to lower aseptic loosening [87]. Unconstrained implants are less forgiving when placed in malalignment or with poor soft tissue stability and have a higher risk of instability compared with constrained options [87]. The semiconstrained TEA was developed in the 1970s to provide inherent stability and the reproducibility of a hinged prosthesis with a “sloppy hinge” to help shield the bone–implant interface and lower aseptic loosening [87]. The loose coupling of the humeral and ulnar components in semiconstrained TEA allows 7 degrees of varus–valgus and 7 degrees of axial rotation enabling forces to be dissipated through the capsule and ligaments [87]. Convertible models allow simpler conversion from unconstrained to semiconstrained implants [87]. A systematic review in 2005 including 86 articles showed 78% good–excellent results for TEA, which were more common for semiconstrained implants (82%) versus unlinked (78%) versus fixed hinge (73%) [87]. A study in 2011 suggested an overall 24.3% complication rate which was slightly lower for linked (25.9%) versus unlinked (27.2%) prostheses [87]. Linked implants did not have higher clinical loosening (5.2%) compared with unlinked (5.2%) in a 2011 study [87]. Clinical instability was lower in linked (1.4%) versus unlinked (4.9%) implants in a 2011 study [87]. A recent review showed decreased aseptic loosening of linked compared with unlinked (p < 0.005) prostheses [87]. Revision was lower for linked (13.8%) versus unlinked (16.3%; p = 0.015) in a recent review [87]. Sanchez-Sotelo and colleagues published results of 461 TEAs done for RA, in which 80% were female, with an average age of 64 years and a BMI of 25 (only 15% had a BMI >30) [87]. This niche patient population had an 11% (71/461) revision rate with revision-free implant survivorship of 92% at 10 years, 83% at 15 years, and 68% at 20 years [87]. Day et al. showed a 248% increase in primary TEAs performed from 1993 to 2007 and a 500% increase in revision TEAs over that time which is expected to continue at 12.8% per year [87]. Currently, there is insufficient evidence to identify the best type of elbow implant, and the choice is determined by surgeons' preference, familiarity, and patients' particular circumstances [19]. Convertible prostheses may provide a solution when elbow stability can be determined intraoperatively, with recent long-term results described as promising [84]. The Discovery Elbow System has facilitated performing the procedure [14]. The results of total elbow arthroplasty with use of a nonconstrained humeral component inserted without cement in patients who have rheumatoid arthritis appear promising [156]. In most cases, elbow function was maintained in the long-term without loosening of the implant for Kudo type-5 total elbow arthroplasty in patients with rheumatoid arthritis [21]. Within the follow-up limitations of a specific report, semiconstrained and unconstrained elbow prostheses seem equally durable [83].

Other Considerations: Total elbow arthroplasty is moving forward with a focus on the evolution of the procedure and issues that could improve clinical outcome in today's practice [26]. The continued success of total elbow arthroplasty will depend on advances in surgical planning, technique, implant design, and materials [3]. Continued advances in exposure, implant design, and complication management are key to making elbow arthroplasty as reliable and lasting as hip or knee arthroplasty [6]. Total elbow arthroplasty designs have evolved, but long-term outcome data remain limited [7]. After implantation of a total elbow implant, there is a significant malalignment between the ulna and the humerus [155]. Greater improvement occurred in terms of relief of pain, functional status, and elbow score in the primary arthroplasty group compared to those following radial head excision and synovectomy in rheumatoid arthritis [92]. Total elbow arthroplasty is very successful in terms of pain relief, motion and function [11]. Several studies report long-term results of total elbow surgery, documenting high percentages of pain relief and functional improvement with low incidence of complications and a high survival rate of the implant [16]. At a minimum of three-year follow-up, revision radiocapitellar arthroplasty by mismatched implant components improved from poor to good and excellent Mayo elbow performance scores with no signs of implant failure on standard radiographs [18]. Interposition arthroplasty can improve elbow motion and function but at the expense of elbow stability despite hinged external fixation [145]. Elbow arthrodesis is reserved for patients with painful arthritis who are not candidates for total elbow arthroplasty, especially individuals who place high demands on the upper extremities [86]. Total elbow arthroplasty, fascial arthroplasty, or even resection arthroplasty in the presence of functional musculature often provides better function of the upper extremity than does elbow arthrodesis [86]. For unilateral arthrodesis of the elbow, a position of 90 to 100 degrees of flexion is desirable to provide the most powerful grip strength [86]. If bilateral elbow arthrodesis is indicated, one elbow should be placed in 110 to 120 degrees of flexion to permit the patient to reach the mouth, and the other should be placed in 45 to 65 degrees to aid in personal hygiene [86].

Complications¶

Total elbow arthroplasty (TEA) is associated with substantial complication and reoperation rates [9]. Reported overall complication rates range from 21% to 53%, with significant complication rates of 24.3% ± 5.8% [260, 261, 117]. Revision rates vary widely, with a meta-analysis reporting 13.5% and other series citing up to 18% [52]. In a cohort of primary and secondary TEA after index intra-articular fracture of the distal humerus, 53% of patients experienced at least one complication [117]. While the overall complication rate was numerically lower after primary TEA (43%) than after secondary TEA (69%), this difference did not reach statistical significance [117]. Complications lead to decreased satisfaction and Oxford Elbow Scores at 3 years, despite no significant differences at 1- or 5-year follow-up [261]. The worst outcomes occur in patients undergoing TEA for fracture sequelae, which carries a relative risk of revision six times higher than inflammatory arthropathy [77]. Conversely, secondary TEA after failed internal fixation in the elderly has shown good functional results and complication rates comparable to index TEA [246]. In United States university medical centers, inpatient complication rates are low, including deep vein thrombosis (0.8%), re-operation (0.5%), and infection (0.4%), with a 30-day readmission rate of 4.4% [222]. Perioperative mortality is reported at 0.6%, most commonly caused by cardiac complications [52].

Infection (PJI): Infection is a dreaded complication of TEA, with an incidence ranging from 0% to 11.5% and an average of 5% to 6% [52]. TEA carries a higher risk of infection compared to other major joint replacements [43]. Patients with rheumatoid arthritis have higher infection rates than those with posttraumatic sequelae [52]. A history of infection is a statistically significant risk factor; in one study, 3 of 9 patients with a history of infections had recurrent infections after TEA placement, and 2 of 3 patients with a history of infected TEA had recurrent infections after reconstruction [80]. Persistent wound drainage is highly indicative of deep infection and predicts the likelihood of subsequent component resection [52]. Periprosthetic joint infection (PJI) is relatively common and difficult to eradicate, making prevention key [268]. Two-stage revision is generally recommended and is the most effective treatment, showing the lowest recurrence rate [52, 281]. Two-stage reimplantation was successful in eradicating deep infection in 36 elbows (69%) [273]. Well-fixed components may be retained during initial debridement with local antibiotics, followed by repeat debridement and re-articulation after intravenous antibiotics [52]. The non-infection related adverse event rate for one-stage revision was 16.7% (95% CI: 3.0–56.4), while for two-stage revision it ranged from 11.8% (95% CI: 4.7–26.6) to 20.0% (95% CI: 3.6–62.4) over a weighted mean follow-up of 3.7 years [216]. No mortality events associated with revision strategy were reported in six studies [216]. Routine administration of vancomycin powder has been adopted by some authors following observed reductions in PJI [276]. Surgical helmet systems do not reduce the incidence of PJI [280]. Shoulder and elbow PJI may be on a temporal decline [97].

Aseptic loosening: Aseptic loosening is the most prevalent reason for revision, accounting for 38% of cases in a systematic review of 9,308 TEAs [94]. It is one of the most devastating problems associated with reconstructive elbow surgery [40, 52]. For semiconstrained prostheses, humeral component loosening has been reduced by improvements in prosthesis design, operative technique, and anatomical understanding [52]. However, use of a shorter (4-inch) stem in semiconstrained TEA resulted in earlier time to revision than longer (6-inch) stems [52]. Humeral stem loosening remains uncommon at approximately 2% at an average of 7 years of follow-up [52]. Ulnar component loosening and osteolysis increased with the addition of a polymethylmethacrylate precoat in the 1990s but have decreased since the surface finish was changed to a plasma spray preparation [52]. In the unnotched group, all aseptic loosening cases occurred at the bone-cement interface within 2 years after TEA [258]. The high rate of component loosening after failed internal fixation may be related to increased pathology and technical difficulty [250]. In a study of Coonrad-Morrey TEA in young patients with post-traumatic sequelae, progressive humeral radiolucent lines were revealed in seven elbows (14%), ulnar radiolucent lines in three elbows (6%), low-grade humeral radiolucency in 15 elbows (31%), and nonprogressive ulnar radiolucent lines in six elbows (12%) [66]. The ulnar component is more commonly affected by aseptic loosening and malalignment in the Kudo elbow prosthesis [111]. Mechanical loosening may be associated with fracture, bone resorption, or cortical expansion, perforation, or thinning [119].

Instability: Instability in the form of dislocation or subluxation is the most common complication requiring revision of unconstrained prostheses, occurring in 9% to 10% of TEAs [52]. True dislocation occurs in fewer than 5% of unlinked implants and is dependent on surgical technique [52]. Appropriate tensioning of the medial and lateral ligament complexes and preservation of the anterior capsule and triceps can help avoid dislocation in unlinked implants [52]. Among revision indications for unlinked prostheses, aseptic loosening and instability remain predominant [28]. Complications for linked prostheses are driven by high torsional stresses at the bone-cement interface and wear-related debris generation [28].

Periprosthetic fracture: Periprosthetic fractures are the third most prevalent reason for revision, accounting for 12% of cases in a systematic review of 9,308 TEAs [94]. They are among the most common indications for reoperation and the most devastating problems associated with reconstructive elbow surgery [52, 40]. Mid-term and long-term studies report failures secondary to periprosthetic fractures for TEA used in distal humerus fractures [29].

Nerve palsy: The most commonly encountered complications include ulnar neuritis and triceps insufficiency [52]. Nerve paresthesias occur in an average of 11% of cases, and nerve entrapment in an average of 3% [52]. Postoperative nerve injury is a common and clinically important complication of revision TEA, affecting approximately one in five cases [28]. The ulnar nerve is most frequently involved, with radial nerve injury accounting for a substantial proportion [28]. Many neuropathies improve during follow-up, but persistent deficits and the need for secondary nerve-related procedures are not uncommon [28]. In a series of 258 humeral component revisions, 7 (2.7%) were complicated by radial nerve palsy [161]. Only 3 of 7 patients (43%) regained function after radial nerve palsy [161]. There was no recovery in 4 out of 5 patients in whom power instruments or ultrasound was used for cement removal, whereas two of three patients who underwent exposure of the radial nerve had return of function [161]. Formal exposure and protection of the radial nerve are predictive of recovery [161]. A 3% incidence of significant ulnar nerve complications after TEA compares favorably with systematic reviews [233]. In a five-year Mayo Clinic experience, eleven ulnar neuropathies (two permanent and nine transient) were reported [220]. Ulnar nerve neuropraxia was reported as a non-infection related adverse event following revision surgery for infected elbow prostheses [216].

Wound complications: Wound problems occur in an average of 14% of cases [52]. Triceps problems occur in an average of 4% of cases [52]. Ankylosis occurs in an average of 4% of cases [52].

Other Considerations: Revision TEA is typically indicated for aseptic loosening, instability, polyethylene wear, infection, or periprosthetic fracture [28]. Revision TEAs are now required in up to one-third of cases within the first decade following primary implantation [28]. Acceptable implant survival rates have been found after 5 and 10 years, with a higher revision rate for the unlinked design and primary TEA due to fracture sequelae [264]. The survivorship at 10 years was 74% (95% confidence interval, 66%-81%, with 11 elbows at risk) for the Souter-Strathclyde elbow arthroplasty, with revision undertaken in 14 elbows (13 patients) by the time of review [64]. For the Pritchard ERS total elbow prosthesis, 15 cases underwent partial revision, the implant was removed in 5 cases, and a complete revision was done in 9 cases; overall, there were 14 failures at an average of 81 months (range, 1-159) [118]. For the GSB III prosthesis, six (43%) of 14 patients had major complications requiring 1 to 8 additional operations (average 3 operations) [217]. Four (29%) implants with gross loosening were revised [217]. Disassembling of the components occurred in 2 patients; one early postoperative disassembled implant required open revision and was subsequently stable, while the other exhibited recurrent instability requiring 4 open reductions and finally a revision procedure with exchange of the prosthesis and additional use of an ulnar lengthening device, which fractured after 5 years and was exchanged [217]. One triceps tendon ruptured and was repaired, but at follow-up the patient had no power for extension [217]. Two elbows with postoperative stiffness had a successful open release [217]. In a five-year Mayo Clinic experience, excluding eleven prostheses with loosening for which revision was necessary, there were forty-four complications (55 per cent) after eighty procedures [220]. Revisions were performed in nineteen (24 per cent) of the eighty elbows; in eleven revisions, the cause was loosening; in seven, deep infection; and in one, an ulnar fracture [220]. Follow-up revealed twenty-nine elbows with radiolucency around the components: in twenty-five about the humeral and in four about the ulnar component [220]. The results of revision at a minimum of two years were inferior to those of primary capitellocondylar total elbow arthroplasty [116]. Revision of a TEA presents major problems to the surgeon, including poor quality of available bone, previously violated soft-tissue planes, and risk to peripheral nerves [71]. Heterotopic ossification and limited motion resulting from previous operations may be present in revision TEA [71]. Revision is performed most frequently for septic or aseptic loosening or for dislocation [71]. When there is only a moderate amount of bone loss and cortical perforation, a standard long-stem implant may be used to bypass cortical defects, potentially supplemented with autogenous bone graft placed in the cortical defects, with or without internal fixation of the fracture [119]. Moderate bone loss (only supracondylar bone remaining) or severe bone loss (only the humeral diaphysis remaining) was noted in twenty-nine of the thirty-three elbows in a series of revision total elbow arthroplasties by Morrey and Bryan [119]. After a minimum duration of follow-up of three years, eighteen (55 percent) of the elbows had a good result and fifteen (45 percent) had a poor result in that series [119]. Another revision procedure was performed in the fifteen elbows that had a poor result, and eight of them eventually had a good result [119]. Bone quality and loss are critical factors in determining revision strategy for TEA [46]. Transient neuropathy of the ulnar nerve and posterior interosseous nerve were the most commonly reported neurological complications in radial head arthroplasty (seven out of 391 cases; 4.73%), with symptoms resolving spontaneously in the majority of cases and no residual disability [195]. There were only two reported cases where transposition of the ulnar nerve was required after radial head arthroplasty [195].

Recovery¶

Light activity (weeks): Activities of daily living are encouraged postoperatively [34]. A lifting restriction of 5 lbs is prescribed during this period [34].

Full activity (months): No extension against resistance is allowed for 6 weeks after surgery in cases where the triceps was detached for exposure [34]. Caution is advised for resuming sport activities due to the risk of intraarticular fractures in maximal loading immediately after surgery [272].

Rehabilitation protocol: Postoperative immobilization in a bulky dressing and splint for 5 days is recommended for primary total elbow arthroplasty patients [34]. Active and passive range of motion is initiated if the wound is sealed at 5 days postoperatively [34]. An extension splint is used at night as needed to maintain full elbow extension [34]. The modified posterior approach enables early mobilization after total elbow arthroplasty [197].

Functional milestones: Satisfactory supportive range of motion was restored to patients' elbow joints during the course of total elbow arthroplasty [178]. Ninety-four percent of patients engaged in moderate-demand activities after total elbow arthroplasty [168]. Forty percent of patients engaged in high-demand activities after total elbow arthroplasty [168].

Other Considerations: Clinical and radiographic evaluation occurs at postoperative intervals of 3 months, 6 months, 1 year, then annually thereafter up to 5 years [34].

Key Evidence¶

[L4] Early results of total elbow arthroplasty are promising in carefully selected patients. [1] (10.1016/0266-7681(86)90168-3)
[L4] The authors conclude that even in the long term (>10 years), results obtained with elbow arthroplasty are approaching those of hip and knee arthroplasty. [2] (10.1016/s1058-2746(96)80002-4)
[L5] The continued success of total elbow arthroplasty will depend on advances in surgical planning, technique, implant design, and materials. [3] (10.5435/jaaos-d-25-00473)
[L4] [5] (10.1016/j.otsr.2013.11.004)
[L5] Continued advances in exposure, implant design, and complication management are key to making elbow arthroplasty as reliable and lasting as hip or knee arthroplasty. [6] (10.1177/1758573216677200)
[L5] Total elbow arthroplasty designs have evolved, but long-term outcome data remain limited. [7] (10.1016/j.hcl.2011.01.003)
[L5] Total elbow arthroplasty remains the most definitive functional procedure for patients with end-stage painful arthritis of the elbow. [8] (10.1097/01.bth.0000181293.38237.f0)
[L4] Total elbow arthroplasty remains associated with substantial complication and reoperation rates. [9] (10.1016/j.jhsg.2026.100981)
[L4] Total elbow arthroplasty has become a reliable treatment option for elbows severely affected by rheumatoid arthritis, with recent reports showing decreased prevalence of complications, maintenance of excellent pain relief, and functional restoration. [10] (10.2106/00004623-199805000-00008)
[Paper] Elbow arthroplasty is very successful in terms of pain relief, motion and function. [11] (10.2174/1874325001105010115)
[L4] The review discusses various approaches to total elbow arthroplasty and their reported outcomes to assist surgeons in making an informed choice. [12] (10.1177/1758573216682479)
[Paper] The Discovery Elbow System has facilitated performing the procedure. [14] (10.1097/00130911-200403000-00008)
[L4] The complication and revision rates are comparable to other indications for elbow replacement surgery. [15] (10.1177/17585732211014832)
[L5] Several studies report long-term results of total elbow surgery, documenting high percentages of pain relief and functional improvement with low incidence of complications and a high survival rate of the implant. [16] (10.1097/00130911-200009000-00011)
[L4] The age at surgery is a risk factor for complications, and the indication for total elbow arthroplasty in patients under 60 should be carefully considered. [17] (10.1016/j.otsr.2013.10.012)
[L4] At a minimum of three-year follow-up, both cases improved from poor to good and excellent Mayo elbow performance scores with no signs of implant failure on standard radiographs. [18] (10.1177/17585732241297152)
[Paper] Currently, there is insufficient evidence to identify the best type of elbow implant, and the choice is determined by surgeons' preference, familiarity, and patients' particular circumstances. [19] (10.1016/j.hcl.2011.01.004)
[L3] In most cases, elbow function was maintained in the long-term without loosening of the implant. [21] (10.1302/0301-620x.99b6.bjj-2016-1033.r2)
[L3] Patients undergoing elective total elbow arthroplasty have slightly higher complication rates than those undergoing shoulder, hip, or knee arthroplasty. [22] (10.1016/j.jhsa.2016.07.007)
[L5] The chosen treatment must allow at least 100° and preferably 120° of flexion–extension at the elbow. [23] (10.1016/j.otsr.2023.103759)
[L3] The Discovery elbow replacement demonstrates early clinical results similar to other semi-constrained total elbow replacements, with continued radiological surveillance warranted for humeral lucency. [24] (10.1302/0301-620x.96b10.33815)
[L4] The review focuses on the evolution of the elbow arthroplasty, from a historic overview, up to the present and addresses issues that could improve the clinical outcome in today's practice. [26] (10.5312/wjo.v7.i1.44)
[L5] The surgical and therapeutic management for total elbow arthroplasty is reviewed, including surgical overview, techniques, stability issues, and a proposed postoperative treatment plan. [27] (10.1197/j.jht.2006.02.010)
[L4] [28] (10.1016/j.jse.2026.04.042)
[L4] [29] (10.1016/j.ocl.2013.03.009)
[L5] Total elbow arthroplasty may be performed in younger patients for whom no other alternatives are available, although joint-preserving procedures for elbow arthritis are generally more successful than other surgical options for shoulder arthritis. [32] (10.3810/psm.2013.02.1998)
[L4] [34] (10.1016/j.jse.2013.12.033)
[L5] Total elbow arthroplasty (TEA) indications have changed markedly in the past decade to address the sequelae of trauma rather than inflammatory conditions. [36] (10.1016/j.ocl.2018.02.009)
[L4] Component alignment, articular configuration, and soft-tissue balance can affect the kinematics of total elbow arthroplasty. [37] (10.1007/s00264-010-0972-1)
[L5] Total elbow arthroplasty is an effective treatment for various conditions about the elbow, with the main goal being pain relief. [38] (10.1053/j.oto.2013.09.002)
[L4] It is a satisfactory alternative to total elbow arthroplasty with lower rates of complications and does not require activities to be restricted to the same extent. [39] (10.1302/0301-620x.100b3.bjj-2017-0865.r1)
[L4] Complications associated with reconstructive elbow surgery persist, often leading to profound and sometimes nonsalvageable disability, with aseptic loosening, infection, and periprosthetic fracture being the most devastating problems. [40] (10.5435/00124635-201106000-00003)
[L4] This retrospective review supports a recommendation for total elbow arthroplasty when strict inclusion criteria are observed. [41] (10.2106/jbjs.d.02871)
[L4] Total elbow arthroplasty carries a higher risk of infection when compared to other major joint replacements. [43] (10.1177/1758573218789341)
[L5] The posterior humeral cortex 35mm proximal to the medial epicondyle lies in the coronal plane of elbow movement. [45] (10.1016/s1058-2746(95)80179-0)
[L5] The article provides a comprehensive review of current strategies to improve diagnosis of failed total elbow arthroplasty and management of bone loss, noting that bone quality and loss are critical factors in determining revision strategy. [46] (10.1016/j.xrrt.2023.02.010)
[L4] Total elbow replacement arthroplasty is effective in relief of pain and restoring hand function. [48] (10.1016/s1058-2746(96)80507-6)
[L4] Functional improvement is possible by means of total elbow replacement when proper indications are satisfied, including patient understanding of risks and ability to comply with postoperative rehabilitation. [49] (10.2106/00004623-198971040-00006)
[L5] Treatment of elbow arthritis must be individualized based on etiology, severity, patient age, and functional demands; nonsurgical management may provide relief in early stages, while surgical options range from arthroscopic debridement for pain at motion extremes to total elbow arthroplasty for pain throughout the arc of motion. [63] (10.1016/j.jhsa.2012.12.037)
[L3] [64] (10.1016/j.jse.2004.02.015)
[L4] [66] (10.1016/j.jse.2022.03.021)
[L2] The range of indications for total elbow arthroplasty is broadening; total elbow arthroplasty for acute trauma and osteoarthritis is becoming increasingly more common. [67] (10.1302/2058-5241.5.190036)
[L4] This is the largest study evaluating the Van Gorder surgical approach to the elbow for primary TEA with an average follow-up of 32 months. [68] (10.1016/j.jse.2021.09.005)
[L4] If excision of the fragments is avoided, original, or near original, anatomy of the elbow joint can be better restored and acceptable outcome obtained with elbow arthroplasty. [69] (10.1067/mse.2001.114261)
[L4] [71] (10.2106/jbjs.03031pp)
[L5] The appropriate treatment for elbow arthritis depends on the etiology, severity, patient age, and functional demands. [72] (10.1016/j.jhsa.2009.02.019)
[L4] With careful patient selection, convertible total elbow arthroplasty provides patients with good to excellent outcomes and substantial improvements in the range of movements. [73] (10.1177/1758573221991511)
[L3] The worst outcomes were found in patients undergoing total elbow replacement for fracture sequelae, where there was a relative risk of revision of 6 compared to inflammatory arthropathy. [77] (10.3109/17453674.2013.784658)
[L4] Survival rates nonetheless remain low and complication rates remain high yet are comparable to those of other elbow arthroplasties. [78] (10.1016/j.jse.2021.08.028)
[L4] [80] (10.1016/s1058-2746(99)90077-0)
[L4] [81] (10.1016/j.jse.2005.09.002)
[L3] [82] (10.2106/00004623-200010000-00003)
[L3] Within the follow-up limitations of this report, the 2 types of elbow prosthesis seem equally durable. [83] (10.1067/mse.2000.109408)
[L4] Convertible prostheses may provide a solution when elbow stability can be determined intraoperatively, with recent long-term results described as promising. [84] (10.2106/jbjs.rvw.18.00127)
[L3] Total elbow arthroplasty for distal humerus fractures provided similar clinical and functional outcomes when performed as a primary procedure or after failed internal fixation. [85] (10.1097/bot.0000000000001631)
[L4] When successful, total elbow arthroplasty provided adequate pain relief and good functional restoration. [89] (10.1016/j.jse.2026.07.008)
[L4] There is radiographic evidence of the restoration of the humeral and ulnar bone stock in the short term, which is encouraging. [90] (10.1097/bth.0b013e318225475d)
[L3] The study suggests that total elbow arthroplasty performed acutely results in satisfactory outcomes and should be a consideration for patients at high risk of failing ORIF or nonsurgical management. [91] (10.1016/j.jhsg.2023.05.006)
[L3] Greater improvement occurred in terms of relief of pain, functional status, and elbow score in the primary arthroplasty group. [92] (10.1016/s1058-2746(96)80077-2)
[L1] [94] (10.1007/s00402-017-2687-x)
[L1] Shoulder and elbow PJI may be on a temporal decline. [97] (10.1016/j.jinf.2020.01.008)
[L5] The kinematics of the elbow deviated increasingly from those of the native joint with a 2 mm to a 4 mm lengthening of the radius. [105] (10.1302/0301-620x.106b10.bjj-2024-0405.r1)
[Paper] The aim of this article is to illustrate our technique for total elbow arthroplasty, acknowledging the key technological advancements and evidence-based techniques that have emerged in the last 2 decades. [107] (10.1002/atn2.70209)
[L3] [111] (10.1111/j.1758-5740.2009.00011.x)
[L4] The author's experience indicates it is now his preferred method for most total elbow arthroplasty cases. [112] (10.1097/00132589-200203000-00006)
[L3] The results of revision at a minimum of two years were inferior to those of primary capitellocondylar total elbow arthroplasty. [116] (10.2106/00004623-199610000-00012)
[L3] [117] (10.1016/j.jsea.2026.100027)
[L4] [118] (10.1016/j.jse.2008.11.014)
[Case_report] [119] (10.2106/00004623-199907000-00015)
[L5] Our approach allows total elbow arthroplasty to be performed without compromise to the triceps insertion and ideal placement of the ulnar component. [122] (10.1097/bte.0000000000000166)
[L4] Total elbow arthroplasty, when carefully planned and executed, can be considered a therapeutic option for flail or grossly unstable elbow articulations, although the complications can be serious. [125] (10.1016/s1058-2746(97)90068-9)
[L5] With optimal total elbow arthroplasty implantation, the general pattern of change of the muscle moment arms with elbow flexion resembled that of the intact elbow, but with increased flexor dominance over the extensors with elbow flexion. [127] (10.1016/s1058-2746(09)80035-9)
[L5] Shoulder abduction results in a varus moment at the elbow. [128] (10.1016/j.jhsa.2018.04.022)
[L4] They propose a new classification of humeral bone loss that will allow for better planning of primary and revision total elbow arthroplasties. [129] (10.1016/s1058-2746(98)90001-5)
[L5] From a biomechanical perspective, the enhancement of elbow stability with a monopolar radial head prosthesis is superior to that with a bipolar design. [132] (10.1016/j.jse.2010.10.033)
[L5] The inclination of the posterior cortex of the humerus 35 mm proximal to the medial epicondyle identifies the coronal plane of elbow movement. [138] (10.1016/s1058-2746(09)80094-3)
[L5] No implant replicated the behavior of the human ulnotrochlear joint, with most designs being less constrained than a normal elbow. [139] (10.1016/j.jse.2004.09.035)
[L5] Cementing a nonanatomic hinge that may not rely on the native elbow soft tissue support can result in a troubling biomechanical environment. [142] (10.1016/j.jhsa.2018.11.020)
[L4] Interposition arthroplasty can improve elbow motion and function but at the expense of elbow stability despite hinged external fixation. [145] (10.1016/j.jse.2007.11.008)
[L5] Insertion of a correctly sized metallic radial head replacement recreates near normal biomechanics of the forearm with no change in the loading characteristics of the interosseous membrane. [147] (10.1302/0301-620x.95b10.31844)
[L4] Total elbow arthroplasty is a surgical option for end-stage elbow arthritis with indications expanding from rheumatoid arthritis to osteoarthritis, post-traumatic arthritis, and acute fractures. [149] (10.1016/j.jhsa.2018.11.005)
[L5] Total elbow arthroplasty is an effective treatment for end-stage arthritis of the elbow, with results in patients with rheumatoid arthritis appearing nearly as free of complications as those performed for other indications, though it should be considered a last step due to the lack of other options after replacement. [153] (10.1016/j.hcl.2010.10.003)
[Paper] After implantation of a total elbow implant, there is a significant malalignment between the ulna and the humerus. [155] (10.1016/j.jseint.2024.08.070)
[L4] The results of total elbow arthroplasty with use of this prosthesis appear promising. [156] (10.2106/00004623-199909000-00008)
[L4] Our short-term results demonstrate that unlinked, noncongruous elbow arthroplasty can be a successful alternative in the management of acute distal humeral fractures, when internal fixation is not a viable option. [157] (10.1016/j.jse.2007.06.011)
[L4] Concomitant total wrist and elbow arthroplasty is a viable option for selected patients with ipsilateral degenerative changes, offering benefits such as reduced recovery time, lower costs, and decreased morbidity compared to two-stage procedures. [159] (10.1055/s-0035-1569483)
[L5] Muscle forces have an important role in stabilizing the capitellocondylar total elbow. [160] (10.1016/s1058-2746(09)80069-4)
[L4] [161] (10.1016/j.jse.2010.08.012)
[L4] Salvage of supracondylar non-union by means of a total elbow arthroplasty is a technically demanding procedure that should be done only when other therapeutic options are unsatisfactory. [163] (10.2106/00004623-198971070-00013)
[L4] Ninety-four percent of patients engaged in moderate-demand activities after total elbow arthroplasty, and forty percent engaged in high-demand activities. [168] (10.1016/j.jse.2013.01.023)
[L5] Overstuffing the radial head prosthesis alters joint kinematics and may lead to pain and degenerative changes. [169] (10.1177/1758573219881772)
[L4] Implant arthroplasty is a therapeutic option in patients with flail and unstable elbows. [172] (10.1016/s1058-2746(96)80078-4)
[L4] Treatment options range from conservative management to open debridement, arthroscopy, and total elbow arthroplasty in selected patients. [173] (10.1111/j.1758-5740.2010.00089.x)
[L4] The valgus angulation of the available elbow designs is discordant with the mean native valgus angulation found in this study, and the valgus laxity of the implants does not cover the variability in the studied population. [175] (10.1016/j.jse.2023.04.017)
[L4] In the course of total elbow arthroplasty, satisfactory supportive range of motion was restored to patients' elbow joints. [178] (10.1136/annrheumdis-2014-eular.2916)
[L4] [182] (10.2106/00004623-198870010-00031)
[L5] The plane through the ridge of the GSN of a healthy proximal ulna could provide a more reliable anatomical landmark to estimate the position of the elbow FE axis compared to the posterior surface (95% CI range: 11°). [186] (10.1016/j.jseint.2024.10.016)
[L4] Elbow HA is an option for young or active patients with end stage elbow arthritis or unreconstructable distal humerus fractures in whom alternative procedures have failed or there are few other options for treatment. [187] (10.1016/j.jse.2015.11.048)
[L5] The radial head prosthesis mimics the mechanics of the native radial head in terms of mean contact area, mean contact pressure, and peak contact pressure; however, different patterns of contact pressure and area curves during elbow flexion-extension were observed. [190] (10.1016/j.jhsa.2018.08.005)
[L5] [194] (10.1097/bte.0000000000000041)
[L4] [195] (10.1177/1758573214524934)
[L4] The modified approach offers excellent exposure of the elbow joint, allows a solid repair of the triceps mechanism, and enables early mobilization after total elbow arthroplasty. [197] (10.1177/1758573214559319)
[L4] [208] (10.1177/1758573216640210)
[L5] [212] (10.1016/j.xrrt.2022.12.003)
[L5] [215] (10.1097/bte.0000000000000154)
[L1] [216] (10.1186/s12891-019-2848-x)
[L4] [217] (10.1016/s1058-2746(00)90042-9)
[L4] [220] (10.2106/00004623-198163070-00002)
[L4] Total elbow arthroplasty performed in United States university medical centers is associated with low in patient complication rates that include DVT 0.8%, re-operation 0.5%, and infection 0.4%. 4.4% of patients were readmitted to the hospital within 30 days of the index procedure. [222] (10.4081/or.2016.6113)
[L4] [224] (10.1097/bth.0000000000000079)
[L2] [230] (10.1016/j.jhsa.2022.07.020)
[L4] A 3% incidence of significant ulnar nerve complications after total elbow arthroplasty compares favorably with systematic reviews. [233] (10.1016/j.jhsa.2015.06.107)
[L4] [235] (10.1016/j.jseint.2024.08.004)
[L5] [237] (10.1016/j.jhsa.2024.09.006)
[L5] [238] (10.1016/j.jse.2011.05.024)
[L4] [242] (10.1097/blo.0b013e31802e1968)
[L4] There is concern about early radiologic loosening of the radial component, though this has not resulted in clinical symptoms or implant failure yet. [243] (10.1016/j.jse.2017.06.037)
[L3] MRI from our institution was able to identify the cause of medial elbow pain in 20 (95%) of 21 throwing athletes. [244] (10.1016/s1058-2746(95)80208-8)
[L4] The radial head arthroplasty diameter can be predicted preoperatively in two-thirds of cases from a simple measurement of the humeral condyle diameter with an appropriate lateral view of a simple radiograph. [245] (10.1016/j.jse.2018.01.017)
[L3] Secondary total elbow arthroplasty after failed internal fixation has shown good functional results and a complication rate comparable to that of index total elbow arthroplasty in the treatment of articular fractures of the distal humerus in the elderly. [246] (10.1016/j.jse.2024.03.032)
[L3] Heterotopic ossification after total elbow arthroplasty is seen more commonly than previously reported. [249] (10.1302/0301-620x.100b6.bjj-2017-0535.r2)
[Abstract] The high rate of component loosening, which is of concern, may be related to the increased pathology and technical difficulty of elbow joint arthroplasty in the setting of prior failed internal fixation. [250] (10.1016/j.jse.2007.02.051)
[L4] All unnotched group aseptic loosening cases occurred at the bone-cement interface within 2 years after total elbow arthroplasty. [258] (10.1177/17585732221150799)
[L3] Poor ulnar cementation may predict radiological loosening and eventual need for revision, but this loosening does not correlate with the patient's clinical outcomes. [259] (10.1016/j.jse.2021.03.063)
[L1] The overall significant complication rate for modern total elbow arthroplasty is 24.3% ± 5.8%. [260] (10.1016/j.jse.2010.08.026)
[L3] Complications occurred in 21% of patients undergoing total elbow arthroplasty and lead to a decrease in satisfaction and Oxford Elbow Score after 3 years, despite no significant differences at 1-year or 5-year follow-up. [261] (10.1016/j.jseint.2021.02.015)
[L4] We report good early to mid-term clinical and radiographic outcomes. [262] (10.1016/j.jseint.2025.101569)
[L4] The overall interobserver reliability of radiographic assessment following press-fit bipolar RHA was poor among experienced elbow surgeons. [263] (10.1177/1758573217719088)
[L3] We found acceptable implant survival rates after 5 and 10 years, with a higher revision rate for the unlinked design and primary TEA due to fracture sequelae. [264] (10.1016/j.jse.2014.02.001)
[Paper] Therefore, pre-operative templating using plain elbow radiographs does not add benefits in pre-operative decision making. [265] (10.1007/s00402-016-2444-6)
[L3] If a radial head prosthesis is used, prosthesis oversizing should be avoided as it may contribute to worse outcome with other radiographic abnormalities. [266] (10.1007/s00264-014-2478-8)
[L4] In this series, 5.3% of the elbows have had a failure of the locking mechanism, which is most likely higher as not all patients have had radiographic follow-up within the last year. [267] (10.1016/j.jse.2005.05.007)
[L5] Periprosthetic joint infection after total elbow arthroplasty is relatively common and difficult to eradicate, with prevention being key. [268] (10.1302/0301-620x.106b11.bjj-2024-0549.r1)
[L5] The case presented represents distal humeral osteolysis associated with gross and microscopically identified polyethylene debris surrounding a cemented semiconstrained total elbow prosthesis. [269] (10.1016/j.jse.2005.02.018)
[L4] However, since the threshold for this surgical procedure is now low and it is also performed in the young and active population, the elbow may be at risk for intraarticular fractures in maximal loading immediately after surgery and some caution for resuming sport activities should be prompted. [272] (10.1155/2011/798084)
[Abstract] Two-stage reimplantation for PJI after TEA was successful in eradicating deep infection in 36 elbows (69%). [273] (10.1016/j.jse.2022.01.066)
[Paper] Further follow-up is required to investigate the radiological changes observed in some of our patients. [274] (10.1007/s00402-015-2191-0)
[L4] Increased incidence of radiolucent lines around the ulnar stem and bushing wear with longer follow-up is of concern and represents the failure mode for this total elbow arthroplasty implant. [275] (10.1016/j.otsr.2013.07.002)
[L3] The reduction in PJI seen in this IVP cohort has changed the practice of the authors, who now routinely administer vancomycin powder for total elbow arthroplasty. [276] (10.1016/j.xrrt.2025.06.013)
[L3] Based on these results, and accepting the limitations of this registry study, we cannot recommend the use of SHSs as a means of infection prevention in primary elbow arthroplasty. [280] (10.1016/j.jse.2024.11.034)
[L4] Two-stage revision was the most effective treatment for elbow PJI, showing the lowest recurrence rate for infection. [281] (10.1016/j.jse.2019.10.002)

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Elbow Arthroplasty

Overview¶

Anatomy & Pathophysiology¶

Bony Anatomy¶

Ligamentous Anatomy¶

Biomechanics and Kinematics¶

Pathophysiology¶

Classification¶

Clinical Presentation¶

History and Symptoms¶

Physical Examination¶

Imaging¶

Investigations¶

History and Physical Examination¶

Imaging¶

Treatment¶

Non-Operative¶

Operative¶

Complications¶

Recovery¶

Key Evidence¶

See Also¶

References¶