Rheumatoid arthritis

Osteoarthritis / post-traumatic arthritis

Acute unreconstructable fracture > 60



- elbow joint commonly involved

- 90% of haemophiliacs





Poor soft tissue cover skin triceps

Under 60 years

Charcot Joint




1. Unlinked


Depend on integrity of MCL / LCL

Risk postoperative instability


2.  Linked


Normal elbow has degree of varus / valgus laxity during flexion / extension


Sloppy hinge / semiconstrained

- metal on poly linked bearing

- some varus / valgus and rotational laxity

- anterior flange on humerus with bone graft to resist rotational force

Coonrad MorreyDiscovery Total ElbowLatitude

Coonrad-Morrey                                          Discovery Elbow                    Latitude


Exposure / Approach / Triceps management


Triceps Options


Triceps off

(some interruption of the triceps mechanism)

Triceps on

Advantage:       Excellent exposure

Disadvantage:  Risk triceps insufficiency

Advantage:         Little risk triceps failure

Disadvantage:     More difficult exposure especially to ulna

Options:          Triceps splitting

                       Triceps reflecting

                       Triceps turn down

Options:   Lateral para-olecranon



Triceps split


AO surgery triceps split approach



- midline split of triceps tendon

- tendon feathered off the olecranon medially with FCU

- tendon feathered off the olecranon laterally with anconeus


Triceps reflecting / Bryan Morrey


AO surgery triceps reflecting approach



- release and protect ulna nerve

- mobilize medial border of the triceps including tendon from olecranon

- anconeus dissected off the ulna

- reflect triceps and anconeus from medial to lateral

- entire extensor mass is subluxated over lateral epicondyle

- leave


Triceps turndown


Inverted V in triceps fascia


Triceps sparing


Vumedi video triceps sparing TEA


AO surgery lateral para-olecranon approach


Para-triceps / lateral para-olecranon approach

- lateral and/or medial windows

- both humerus and ulna are typically instrumented through a lateral window to protect the ulna nerve




Dachs et al JSES 2015

- compared 46 triceps off to 37 triceps on approach

- no triceps ruptures in triceps on approach

- 7/46 (15%) incidence of triceps rupture in triceps off approach

- 3 patients who underwent triceps repair developed deep infections


Technique Total Elbow Arthroplasty


Vumedi video triceps sparing TEA


Vumedi video Coonrad-Morrey approach and prosthesis


JBJS Essential Surgical Technique






Lateral decubitus

- can limit hyperflexion of elbow for instrumentation humerus / ulna


Supine with arm over patient

- requires arm holding by assistant


Posterior Approach

- full thickness skin flaps

- identify and protect ulna nerve


Total Elbow Ulna NerveUlna nerve 2


Triceps on / triceps off approach


Distal Humerus

- release LCL / MCL from humerus and tag for later repair

- elevate anterior capsule off humerus


Dislocate Elbow




1.  Size capitellum and trochlea with spool

- insert into olecranon and over radial head


2.  Prepare ulna

- resect olecranon fossa

- can remove tip olecranon

- find entry to IM canal & pass IM guide

- prepare canal

- insert trial ulna stem


3.  Prepare humerus

- rough cut trochlea

- find entry to IM canal & pass IM guide

- ensure correct rotation (5 degrees internal rotation)

- use IM rod to attach jig for distal humeral preparation

- release anterior capsule from humerus for anterior flange

- prepare humeral canal

- insert trial humeral stem


4.  Trial reduction


5.  Insert cement restrictors / implant ulna and humeral prosthesis


6.  Insert bone graft under anterior flange


7.  Link components


8.  Repair collaterals if needed


Post op


Splint 2 weeks till wound healed

Then active ROM




Davey et al JSES 2021

- systematic review of TEA with 10 years follow up

- 1429 elbows

- overall revision rate at 10 years 15%

- loosening at 10 years 13%

- infection 3%

- dislocation 4%

- nerve injury 2%




Intraoperative fracture


Humeral condyles


Ulna at risk

- slight bend / small diameter / relatively thin cortical bone

- perforations can allow cement extrusion






Progressive lucency on xray

ESR / CRP - not always helpful, especially in patients with inflammatory arthritis


Open biopsy and culture


Infected TEA 1TEA Infected 2


Risk factors for infection


Watts et al Should Elbow 2019

- previous surgery

- younger patients

- previous infection

- rheumatoid arthritis

- obesity / diabetes

- drainage post-op / delayed wound healing




Gutman et al JSES 2020

- systematic review of 309 TEA infections

- Staph aureus most common (42%) followed by coag neg Staph 33%

- irrigation and debridement 56%

- resection arthroplasty 71%

- one stage revision 67%

- two stage revision 81%




JBJS surgical technique elbow resection deep infection


TEA first stage 1TEA first stage 2


Resection arthroplastyResection arthoplasty 2


Triceps failure




Meijering et al JBJS Rev 2021

- systematic review of 4825 TEAs

- triceps insufficiency 4.5%

- 22% in revision TEA

- 10% in TEA for post-traumatic OA

- highest with triceps reflecting approach




Direct repair

Anconeus rotational flaps

Achilles tendon allograft




Celli et al JBJS Am 2005

- 16 cases triceps insufficiency

- combination repair / anconeus flap / achilles allograft

- 14/16 good or excellent


Kwon et al Orthopedics 2021

- 14 cases of achilles allograft reconstruction

- bone plug inserted into olecranon

- 11/14 good or excellent results


Aseptic Loosening


Voloshin et al JBJS 2011

- systematic review of 3000 TEA

- loosening rates 10% for unlinked and 14% for linked prosthesis


Total elbow loose humeral component




Morrey et al JBJS Am 2013

- revision with allograft - prosthesis composite

- 25 patients

- one nonunion / one malunion

- 84% TEA survival


Revision TEA allograft 1Revision TEA Allograft 2

Ulna allograft - prosthetic revision TEA




Voloshin et al JBJS 2011

- systematic review of 3000 TEA

- instability - dislocation / subluxation

- 5% for unlinked and 1% for linked prosthesis

- occurs in linked prosthesis by failure of constraint mechanism


Periprosthetic Fracture




Ulna nerve injury


Partial / Radio-capitellar arthroplasty


Lateral TEA 1Lateral TEA 2


Watkins et al Bone Joint J 2018

- 30 elbow undergoing lateral resurfacing

- 100% survival at 8 years

- improved outcome scores and ROM