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1 Review Article Total Elbow Arthroplasty: Current Options Andrew Choo, MD Matthew L. Ramsey, MD From the Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA. Dr. Ramsey or an immediate family member has received royalties from, serves as a paid consultant to, and has received research or institutional support from Integra and Zimmer and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the Philadelphia Orthopaedic Society, the Rothman Institute, and the Rothman Orthopaedic Specialty Hospital. Neither Dr. Choo nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article. J Am Acad Orthop Surg 2013;21: JAAOS Copyright 2013 by the American Academy of Orthopaedic Surgeons. Abstract Total elbow arthroplasty (TEA) has changed considerably in the past three decades. Based on the good long-term results with TEA in patients with rheumatoid arthritis, the indications expanded to include management of acute traumatic and posttraumatic conditions in young, higher-demand patients. Today, unlinked, linked semiconstrained, and convertible devices are available. The high complication rate with earlier surgeries led to surgical advances such as new cementing technique and a focus on managing the triceps. Complications such as infection, aseptic loosening, polyethylene wear, periprosthetic fracture, triceps insufficiency, wound breakdown, and ulnar nerve injury will continue to spur the evolution of surgical technique and implant design. Refinement of surgical indications and improvement in implant fixation, polyethylene design, component implantation, and pathology-specific implants will determine the future success of TEA. Normal elbow function requires a pain-free, mobile, and stable joint. Disorders that compromise one or more of these basic elements can lead to functional impairment. The earliest efforts at total elbow arthroplasty (TEA) were custom designs that replaced the ulnohumeral joint to address instability resulting from bone loss and destruction of the elbow. These early attempts at hinged elbow arthroplasty were compromised by poor fixation of the implant to bone and inferior implant design, resulting in high failure rates due to early loosening. Improvements in the understanding of elbow biomechanics, surgical technique, and implant materials and design have marked the modern era of TEA. Challenges remain, however, that continue to drive advances in the field. Total Elbow Arthroplasty: Current Status Implant Design The lessons learned from early fully constrained devices as well as a large body of biomechanical data proved that a simple hinge did not replicate the mechanics of the elbow. This knowledge led to the development of two implant design concepts that predominate today joint resurfacing and linked prostheses. With joint resurfacing, the collateral ligaments are preserved to maintain stability. The success of resurfacing implants depends on the integrity of the soft-tissue envelope and the presence of adequate bone stock to support the prosthesis. The stresses across the elbow are absorbed, in part, by the ligamentous constraints, which theoretically results in lower July 2013, Vol 21, No 7 427

2 Total Elbow Arthroplasty: Current Options Figure 1 Lateral radiograph demonstrating hypertrophy of the bone graft behind the anterior flange of the humeral component in a linked total elbow arthroplasty, which is one indication that the component is bearing load. rates of implant loosening. Unlinked designs demand precise replication of the axis of rotation. Poor component alignment and ulnohumeral incongruity result in high failure rates. 1 With linked prostheses, stability is provided through a coupled articulation between the humeral and ulnar components. Modern linked implants have been modified from fully constrained articulations to semiconstrained designs that allow a few degrees of varus-valgus and rotational laxity. This reduces stress on the bone-cement interface and the incidence of loosening. 2 In theory, unlinked implants should be more prone to instability, whereas linked implants should show greater rates of loosening. In practice, cases series have demonstrated satisfactory midterm outcomes with both types of implant. 3,4 A recent review of the literature Figure 2 Photograph of a cross-sectional view of a newer total elbow design with an increased amount of polyethylene and more conforming surfaces between the humeral and ulnar components than existed in earlier designs. showed equal rates of clinical loosening (5.2%); however, when both clinical and radiographic evidence of loosening was taken into account, unlinked designs were favored over linked, semiconstrained implants. 4 The few studies that directly compare unlinked and semiconstrained linked implants generally have found improved survivorship with the semiconstrained linked design; however, prospective data are lacking. 5-7 The role of the radial head in TEA has not been well defined. Potential benefits of maintaining the radial head include better distribution of load across the joint and improved valgus stability. 8 In practice, unlinked implant systems that incorporate a radial head component have failed as a result of instability, wear, and loosening. Poor implant design and component malposition contributed to failure. 1 The radial head is not required for stability in linked designs. The decision to débride or resect the radial head is made based on mechanical symptoms of impingement or pain, and this option is most commonly required in patients with rheumatoid arthritis. Several additional design features have improved the success of TEA. The use of stems on the humeral and ulnar components has improved implant fixation and resulted in lower rates of loosening. 9 In addition, an extracortical anterior flange on the humeral component helps resist the posteriorly directed and rotational forces across the elbow. The importance of the anterior flange in resisting these forces is demonstrated by incorporation and hypertrophy of the bone graft placed between the flange and the anterior cortex of the humerus (Figure 1). Recently, attention has been focused on the articulation between the humeral and ulnar components. Concerns regarding bearing wear and the possible link to osteolysis have prompted the development of newer bearing designs that include conforming polyethylene and metallic bearing surfaces in addition to an increased amount of polyethylene in the bushing (Figure 2). To date, there are no long-term data that demonstrate improved implant longevity with alterations in bearing design and amount of polyethylene. Triceps Approaches Management of the triceps is guided by the underlying pathology, implant type, and surgeon preference. The main types of approach used in TEA are triceps-splitting, -reflecting, and -sparing. Triceps-splitting approaches involve either longitudinal division of the triceps in continuity with the forearm fascia over the dorsal ulna or splitting of the proximal triceps muscle belly with a V-shaped turndown of the triceps tendon and leaving intact its insertion on the olecranon. The latter approach allows for lengthening of the extensor mechanism in cases of extension contracture. Traditionally, the triceps-reflecting (ie, Bryan-Morrey) approach has 428 Journal of the American Academy of Orthopaedic Surgeons

3 Andrew Choo, MD, and Matthew L. Ramsey, MD been used for elbow replacement. The triceps is reflected from medial to lateral in continuity with the anconeus muscle (Figure 3). At the conclusion of the surgery, the triceps is reattached to the ulna through cruciate tunnels using nonabsorbable suture passed through the triceps tendon (Figure 4). An additional horizontal tunnel allows passage of suture to cinch the triceps securely to the olecranon to prevent synovial fluid extravasation behind the repair. Due to increased awareness of triceps insufficiency as a complication of a triceps-reflecting approach, many surgeons have sought to maintain the integrity of the triceps intraoperatively. A triceps-sparing approach has been advocated for TEA to manage acute fracture of the distal humerus. 10,11 Removal of the distal fracture fragments helps to maintain the triceps and achieve adequate exposure for component implantation (Figure 5). A triceps-sparing approach can also be used for TEA when the distal humerus remains intact, although it is more difficult to Figure 3 gain the necessary exposure for component insertion. The medial and lateral borders of the triceps are mobilized along the supracondylar columns (Figure 6). The common extensor muscles and flexor-pronator mass are released from the medial epicondyle. The humerus can be delivered through the lateral soft-tissue window to complete humeral prepa- Illustration of the Bryan-Morrey triceps-reflecting approach for total elbow arthroplasty, which maintains the continuity of the triceps with the anconeus. The triceps and anconeus muscle are reflected from medial to lateral. (Adapted with permission from the Mayo Foundation for Medical Education and Research, Rochester, MN.) Figure 4 Illustration demonstrating meticulous repair of the reflected triceps performed through cruciate drill holes and a horizontal cinch stitch. A, The appearance of cruciate drill holes in the ulna. B, Suture is weaved through the triceps tendon and passed through cruciate drill holes. C, The triceps suture is tied off the lateral side of the ulna. D, A cinch stitch is passed through a transverse drill hole around the triceps tendon (arrow). (Adapted with permission from the Mayo Foundation for Medical Education and Research, Rochester, MN.) July 2013, Vol 21, No 7 429

4 Total Elbow Arthroplasty: Current Options Figure 5 Figure 6 Illustration of a triceps-sparing approach used in performing total elbow arthroplasty following fracture. The space for implanting the components is created by resecting the fracture fragments. (Adapted with permission from the Mayo Foundation for Medical Education and Research, Rochester, MN.) ration. The ulna is exposed by supinating the forearm and turning the triceps and anconeus back on itself as a unit. Outcomes In appropriately selected patients, TEA provides predictable pain relief and functional improvement. A large body of literature exists on the pathology-specific results and complications of TEA. 7,10-16 These data define the expectations for patients and highlight areas for improvement. In patients with rheumatoid arthritis, TEA provides reliable pain relief and functional improvement. 7,17 In a study with 10- to 15-year follow-up, Gill and Morrey 17 reported excellent pain relief and restoration of functional range of motion (ROM) as well as a 92.4% rate of survivorship free of revision at 10 to 12 years. Despite these encouraging results, the Illustrations demonstrating medial dissection to create a window for exposure of the ulna (A) and lateral dissection to create a window for exposure of the humerus (B). (Adapted with permission from Pierce TD, Herndon JH: The triceps-preserving approach to total elbow arthroplasty. Clin Orthop Relat Res 1998;[354]: ) complication rate was approximately 14% and included triceps avulsion, deep infection, periprosthetic fracture, and aseptic loosening. All but one of these patients required reoperation. Currently, the indications for TEA are growing most rapidly for the late sequelae of trauma (ie, posttraumatic conditions) and acute traumatic injuries of the elbow Remarkable variability exists in the pathologic processes in these patients. Although each pathology presents unique challenges, TEA is often the most reasonable option for pain relief and functional improvement. The results of TEA for posttraumatic conditions demonstrate the ability to achieve functional ROM and good patient satisfaction. 16,18 However, the success of arthroplasty in this group is tempered by a complication rate of 27% to 43% and a reoperation rate of 22% to 28%. 16,18 The nature of the complications tends to be time-dependent, with infection causing early failure, and mechanical causes (ie, bushing wear, component loosening, and fracture) contributing to intermediate or late failure. Higher failure rates were seen in patients aged <60 years. 18 In appropriately selected patients, the use of TEA in the management of distal humerus nonunion is an at- 430 Journal of the American Academy of Orthopaedic Surgeons

5 Andrew Choo, MD, and Matthew L. Ramsey, MD tractive alternative to internal fixation. The immediate functional improvement can be gratifying. However, the encouraging results are associated with a reoperation rate of 35%, and the rate of implant survival free of removal or revision is only 65%. 14 The complications in this study were predominantly aseptic loosening, wound complications, and periprosthetic and component fracture. A subset of patients with distal humerus nonunions presents clinically with dysfunctional instability of the extremity. This condition is characterized by dissociation of the forearm from the brachium, which compromises the stable fulcrum required for useful elbow function (Figure 7). With TEA, the extremity is realigned through the linked articulation between the humeral and ulnar components. TEA for distal humerus fractures differs from replacement for other posttraumatic conditions in that it is performed to manage acute trauma rather than the late sequelae of trauma. In the initial report by Cobb and Morrey, 10 TEA was used to treat older patients with unreconstructable fractures of the distal humerus, many of whom had preexisting rheumatoid destruction of the elbow (Figure 8). Since then, several other authors have reported excellent results with the use of linked TEA to manage acute fractures of the distal humerus A recent prospective, randomized controlled trial comparing open reduction and internal fixation with TEA demonstrated better functional outcomes, better postoperative ROM, and fewer reoperations following arthroplasty. 11 Although this powerful study provides a strong argument for TEA, longterm follow-up studies are needed to fully define the early advantages of replacement weighted against the long-term complications and failures. Figure 7 Clinical photograph (A) and radiograph (B) demonstrating dysfunctional instability of the elbow. The forearm is displaced medial to the humerus and contracted proximally. Figure 8 Preoperative AP radiograph (A) and 5-year postoperative lateral radiograph (B) of the elbow in an elderly patient with a comminuted distal humerus fracture that was managed with total elbow arthroplasty. (Reproduced with permission from Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am 1997;79[6]: ) July 2013, Vol 21, No 7 431

6 Total Elbow Arthroplasty: Current Options Figure 9 Lateral radiograph demonstrating rapidly progressive osteolysis around a polymethyl methacrylate precoated ulnar component. Complications The rates and types of complications following TEA are well described in the literature. 4,19-24 Infection is the most devastating complication affecting long-term implant survival. Aseptic loosening, polyethylene wear and osteolysis, periprosthetic fracture, and triceps insufficiency are known causes of failure and can result in the need for revision surgery. Wound complications and ulnar nerve complications, although less perilous to implant retention, are relatively common after TEA. The rate of infection following TEA ranges from 3% to 11%. 25 Several aspects of the surgical technique can influence infection rates. Prevention is achieved with careful softtissue handling, the use of perioperative antibiotic prophylaxis and antibiotic-impregnated cement, and meticulous postoperative wound management. The diagnosis of infection after TEA requires a high index of clinical suspicion because the laboratory studies used to aid in diagnosis often are of limited value. Management of an infected TEA takes into consideration the timing of infection, component fixation, and the infecting organism. Irrigation and débridement with retention of the components may be successful in select cases, but certain glycocalyxproducing organisms are difficult to eradicate. Implant retention is nearly impossible in the setting of Staphylococcus epidermidis infection. 23 A staged reimplantation or resection arthroplasty is required in those circumstances. 19,23 With the use of improved implant designs and modern cement techniques, the clinical rate of aseptic loosening has decreased considerably, although it still stands at approximately 2% to 9%. 3,4,9 The rate of radiographic loosening is even higher and seems to occur most frequently with linked, semiconstrained implants. 3,4 A unique cause of aseptic loosening was reported in a subgroup of patients in whom an ulnar component was inserted with a polymethyl methacrylate precoated surface preparation. 26 In this circumstance, the osteolysis is identified initially at the tip of the ulnar component, with rapid progression and eventual aseptic loosening of the implant (Figure 9). Loosening of the ulnar component has also been reported due to anterior impingement causing a distraction force on elbow flexion. The offending structures can include soft-tissue scar, a protruding cement mantle, bone, and the anterior flange of the humeral component. 27 Wear of the polyethylene bearing surface is expected in any joint arthroplasty. 20,21 Implants that have been in place for decades have demonstrated polyethylene wear with well-maintained bone-cement and cement-implant interfaces. Isolated polyethylene wear may be managed with bushing exchange provided the implants remain well fixed. 21 Periprosthetic fractures typically occur around a stem that is loose. The classification of periprosthetic fractures following TEA is described based on the fracture location, implant fixation, and associated bone loss 22 (Figure 10). Fractures that do not compromise function or the stability of a well-fixed implant may be managed nonsurgically. However, fractures that either occur in association with a loose stem or compromise function because of their location often require fracture fixation or implant revision. Triceps insufficiency following TEA is related to poor tissue quality and manipulation of the triceps intraoperatively. Triceps insufficiency has been recognized in 1% to 5% of patients with rheumatoid arthritis. 4 Two systematic reviews of the literature found an overall rate of 2% to 3%. 3,4 Although one study found no significant difference in rates of triceps insufficiency by surgical approach, 4 the other found that a V-shaped tongue approach was associated with the lowest rate of triceps failures postoperatively (0.56%). 3 Triceps-reflecting approaches, such as the Bryan-Morrey approach, demonstrate a triceps-associated complication rate of 2.8%. 3 In this same study, complete release of the triceps tendon from the ulna resulted in an 11% rate of triceps insufficiency. Use of a triceps-preserving approach was not evaluated in either literature review. Once triceps integrity has been lost, it can be challenging to surgically reestablish meaningful extension. Occasionally, primary repair of a failed triceps may be successful, provided the failure is identified early. With the triceps-reflecting approaches, failure often occurs when the triceps, in continuity with the anconeus, rolls off the lateral aspect of the ulna. When primary repair is not possible, it may be necessary to slide the anconeus to reestablish the continuity of the extensor mechanism (Figure 11) or to perform allograft reconstruction 28 (Figure 12). Wound complications after TEA are recognized to occur due to the subcutaneous nature of the joint and 432 Journal of the American Academy of Orthopaedic Surgeons

7 Andrew Choo, MD, and Matthew L. Ramsey, MD Figure 10 Figure 11 Illustration of the Mayo classification of periprosthetic fractures following total elbow arthroplasty. Type I, fracture of the humeral condyles and olecranon. Type II, humeral and ulnar shaft fracture along the length of the stem. Type III, fracture past the tip of the prosthesis. (Reproduced with permission from the Mayo Foundation for Medical Education and Research, Rochester, MN.) Figure 12 Illustration of the development of the Kocher interval between the anconeus and the flexor carpi ulnaris, along with the technique of sliding the triceps-anconeus composite medially to manage deficiency of the triceps insertion. (Adapted with permission from the Mayo Foundation for Medical Education and Research, Rochester, MN.) Illustration of the use of an Achilles tendon allograft to manage triceps insufficiency. In this case of a deficient olecranon, the calcaneus is maintained at the Achilles tendon insertion and is attached to the native ulna using screw fixation. (Adapted with permission from the Mayo Foundation for Medical Education and Research, Rochester, MN.) the often-compromised soft-tissue envelope. In one study, a 5.5% rate of wound complications was reported within 4 weeks of TEA, including delayed healing, drainage, hematoma, and dehiscence. 29 Of those patients, approximately 25% progressed to a septic elbow. Ulnar nerve complications are common with elbow surgery, including TEA. Although reported rates in the historical literature vary widely, larger systematic reviews have indicated the rate of permanent nerve injury to be between 2% and 5%. 3,4 There may be a trend toward a lower incidence of injury when the nerve is transposed at the time of surgery; July 2013, Vol 21, No 7 433

8 Total Elbow Arthroplasty: Current Options Figure 13 Lateral radiograph of an uncemented Kudo total elbow implant (Biomet). Note the wellfixed humeral component and the aseptic loosening of the ulna. however, this has not been prospectively studied. 4 The Future of Total Elbow Arthroplasty TEA has evolved substantially in the past decades. However, several challenges remain that will define the evolution of TEA. These challenges include the shift in indications toward posttraumatic and acute traumatic conditions, implant fixation to bone, and polyethylene wear and osteolysis. In response to these and other difficulties, component implantation techniques and pathologyspecific implants are being further refined. Indications The early success with TEA in the rheumatoid population has led to an expanded application of TEA to more demanding pathology. An analysis of all primary TEAs done in New York State from 1997 to 2006 showed that in 1997, 43% were performed to manage traumatic conditions and 48% were done to manage inflammatory arthritis. 30 By 2006, 69% of TEAs were associated with trauma, with only 19% performed to manage inflammatory arthritis. The mean overall patient age was 58.3 years, and the average age of patients with a traumatic condition was 58.5 years. As the indications for TEA continue to shift toward acute traumatic and posttraumatic conditions in younger, higher-demand patients, the rate of complications will increase, and implant durability will be challenged. 14,16,18 Implant Fixation Failures of early TEAs were predominantly related to loosening. Implant fixation to bone improved considerably with the introduction of polymethyl methacrylate. The application of modern cement techniques in TEA has improved the mechanical fixation of implant to bone. These techniques include the use of cement restrictors to occlude the canal, delivery of cement in a liquid state, and pressurization of the cement. The natural evolution in implant fixation would seem to be from cemented to uncemented fixation. Uncemented fixation has been used sparingly in modern TEA. The humeral component has performed well in an uncemented application in the Kudo implant system (Biomet). 31,32 However, uncemented fixation of the ulnar component has demonstrated an unacceptably high loosening rate, and it is recommended that the ulnar component be cemented (Figure 13). Uncemented fixation remains an attractive option for the ulnar component. In the future, improved implant design with better canal fill and surface finish, coupled with more precise canal preparation, may make it possible to achieve successful uncemented insertion of the ulnar component. Polyethylene Wear and Osteolysis Polyethylene wear of the bearing surface is expected with any metal-onpolyethylene articulation. Polyethylene bushing wear, as an isolated process, has received little attention in the literature. 21 However, concerns about polyethylene wear and bushing failure have prompted the introduction of new bearing designs with increased thickness of the polyethylene bearing and increased conformity of the articulation with the intent of reducing bushing wear. No reports have demonstrated either a reduction in polyethylene wear or increased implant longevity with these designs, however. Although polyethylene bushing wear is expected, its relationship to the development of osteolysis is poorly understood. 20,21 Some authors believe that osteolysis is the result of the biologic response to polyethylene wear debris; 20 however, it is most commonly encountered in association with a loose implant. A common clinical scenario in which osteolysis is encountered is the loosening of a cement precoated ulnar component. 26 In this setting, cement, bone, polyethylene, and titanium wear particles are found in the periarticular soft tissues and are embedded in the polyethylene bushing, which contributes to third-body wear (Figure 14). In the presence of multiple types of particulate debris, it is impossible to implicate any one element as having initiated the biologic process leading to osteolysis. Presumably, osteolysis is a multimodal process related more to particulate debris caused by loosening than to wear of the polyethylene alone. 20 Component Implantation The accuracy of component implantation is believed to play a critical 434 Journal of the American Academy of Orthopaedic Surgeons

9 Andrew Choo, MD, and Matthew L. Ramsey, MD Figure 14 Intraoperative photograph of a loose polymethyl methacrylate precoated ulnar component with metallic wear debris staining the soft tissues. (Reproduced with permission from Lee BP, Adams RA, Morrey BF: Wear and elbow replacement, in Morrey BF, Sanchez-Sotelo J, eds: The Elbow and its Disorders, ed 4. Philadelphia, PA, Saunders Elsevier, 2009, pp ) role in both implant survival and the stability of the unlinked components. Failure to reestablish the flexion axis and malpositioning of the ulnar component have been identified as risk factors for accelerated bushing wear and increased humeral stem loading of linked implants and for maltracking and instability of unlinked implants. With currently available implant systems, replication of the flexion axis of the elbow is subject to considerable error. 33 Computerassisted component implantation has demonstrated that stem abutment in the intramedullary canal often prevents accurate restoration of the flexion-extension axis. 34,35 Future implant designs may include the development of multiple implant options that provide variability in the implant flexionextension axis relative to the component stem to avoid stem abutment in the canal. 34,35 Whether computerassisted surgery will prove to be of value is not yet clear. Improvements in the instruments used during implantation would facilitate better surgical reproducibility. Pathology-specific Implant Options The implant options continued to evolve. Distal humeral hemiarthroplasty (DHH) and unicompartmental radiocapitellar arthroplasty have been developed in response to problems that arise out of the expanding indications for arthroplasty to younger, high-demand patients. DHH has been infrequently used to manage a variety of pathologic conditions affecting the elbow, including trauma, inflammatory arthritis, and tumors. It has recently been reintroduced to address unreconstructable fractures of the distal humerus in patients who are too young for TEA. 36,37 Initially, hemiarthroplasty was introduced to manage isolated unreconstructable articular fractures. Due to the early success with this technique, the indications have expanded to include acute trauma, salvage of failed fracture fixation, malunion or nonunion, and tumors of the distal humerus. To use a humeral component as a hemiarthroplasty, the geometry of the articular surface must recreate the native anatomy. Ideally, it should be easily convertible to a TEA either acutely or at a later date. Recently, a small case series documented the early experience with DHH, 36 from which three conclusions can be drawn. First, pain relief and functional improvement can be expected in the management of acute distal humerus fractures. Second, results tend to be better with acute fractures than with late reconstruction for nonunion, malunion, or failed internal fixation. Finally, DHH is less effective for managing chronic conditions such as rheumatoid arthritis and hemophilia than for managing acute traumatic conditions. Although only short- to medium-term follow-up is available, the unique complication of ulnar wear has been seen, in addition to problems common to all elbow arthroplasty such as wound complications, triceps insufficiency, periprosthetic fracture, and neurapraxia. 38,39 Although DHH seems to be an attractive option in select patients, its widespread application should be delayed until longterm results are available. Unicompartmental replacement of the radiocapitellar joint has been developed to treat patients with radiocapitellar arthritis. These implants typically incorporate a stemmed metallic capitellar component that articulates with a metal-backed polyethylene radial head component (Figure 15). The indications for radiocapitellar replacement include lateral compartment chondral damage to the capitellum and radial head. Scant information exists regarding the clinical performance of these implants. 40 July 2013, Vol 21, No 7 435

10 Total Elbow Arthroplasty: Current Options Figure 15 Illustration of a radiocapitellar replacement that includes a metallic capitellum and a metalbacked polyethylene radial head. (Adapted with permission from Hughes JS, Morrey BF, King GJ: Unlinked arthroplasty, in Morrey BF, Sanchez-Sotelo J, eds: The Elbow and its Disorders, ed4. Philadelphia, PA, Saunders Elsevier, 2009, pp ) Summary TEA has changed considerably in the past several decades. Advances in implant design and surgical technique resulted in early success in patients with rheumatoid arthritis. As a result, the indications have expanded to include acute traumatic and posttraumatic conditions in young, higher-demand patients. The reported complications in such patients highlight the challenges that remain and continue to fuel the evolution of TEA. Continued refinement is expected in the indications, surgical technique, and implant design to meet the needs of a changing patient population. References Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, reference 11 is a level I study. References 3-7, 12, 26, and 32 are level III studies. References 1, 2, 10, 13-19, 21-24, 27-31, and are level IV studies. References 8, 9, 36, and 37 are level V expert opinion. References printed in bold type are those published within the past 5 years. 1. van Riet RP, Morrey BF, O Driscoll SW: The Pritchard ERS total elbow prosthesis: Lessons to be learned from failure. J Shoulder Elbow Surg 2009; 18(5): Morrey BF, Adams RA: Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am 1992;74(4): Little CP, Graham AJ, Carr AJ: Total elbow arthroplasty: A systematic review of the literature in the English language until the end of J Bone Joint Surg Br 2005;87(4): Voloshin I, Schippert DW, Kakar S, Kaye EK, Morrey BF: Complications of total elbow replacement: A systematic review. 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Philadelphia, PA, Saunders Elsevier, 2009, pp Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am 1997; 79(6): McKee MD, Veillette CJ, Hall JA, et al: A multicenter, prospective, randomized, controlled trial of open reduction: Internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg 2009; 18(1): Frankle MA, Herscovici D Jr, Di- Pasquale TG, Vasey MB, Sanders RW: A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma 2003;17(7): Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement. 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11 Andrew Choo, MD, and Matthew L. Ramsey, MD 24. Yamaguchi K, Adams RA, Morrey BF: Semiconstrained total elbow arthroplasty in the context of treated previous infection. J Shoulder Elbow Surg 1999; 8(5): Cheung E, Yamaguchi K, Morrey BF: Treatment of the infected total elbow arthroplasty, in Morrey BF, Sanchez- Sotelo J, eds: The Elbow and Its Disorders. Philadelphia, PA, Saunders Elsevier, 2009, pp Jeon IH, Morrey BF, Sanchez-Sotelo J: Ulnar component surface finish influenced the outcome of primary Coonrad-Morrey total elbow arthroplasty. J Shoulder Elbow Surg 2012;21(9): Cheung EV, O Driscoll SW: Total elbow prosthesis loosening caused by ulnar component pistoning. J Bone Joint Surg Am 2007;89(6): Sanchez-Sotelo J, Morrey BF: Surgical techniques for reconstruction of chronic insufficiency of the triceps: Rotation flap using anconeus and tendo Achillis allograft. J Bone Joint Surg Br 2002; 84(8): Jeon IH, Morrey BF, Anakwenze OA, Tran NV: Incidence and implications of early postoperative wound complications after total elbow arthroplasty. J Shoulder Elbow Surg 2011;20(6): Gay DM, Lyman S, Do H, Hotchkiss RN, Marx RG, Daluiski A: Indications and reoperation rates for total elbow arthroplasty: An analysis of trends in New York State. J Bone Joint Surg Am 2012;94(2): Brinkman JM, de Vos MJ, Eygendaal D: Failure mechanisms in uncemented Kudo type 5 elbow prosthesis in patients with rheumatoid arthritis: 7 of 49 ulnar components revised because of loosening after 2-10 years. Acta Orthop 2007; 78(2): van der Heide HJ, de Vos MJ, Brinkman JM, Eygendaal D, van den Hoogen FH, de Waal Malefijt MC: Survivorship of the KUDO total elbow prosthesis: Comparative study of cemented and uncemented ulnar components. 89 cases followed for an average of 6 years. Acta Orthop 2007;78(2): Brownhill JR, Furukawa K, Faber KJ, Johnson JA, King GJ: Surgeon accuracy in the selection of the flexion-extension axis of the elbow: An in vitro study. J Shoulder Elbow Surg 2006;15(4): Brownhill JR, King GJ, Johnson JA: Morphologic analysis of the distal humerus with special interest in elbow implant sizing and alignment. J Shoulder Elbow Surg 2007;16(3 suppl):s126- S Brownhill JR, Mozzon JB, Ferreira LM, Johnson JA, King GJ: Morphologic analysis of the proximal ulna with special interest in elbow implant sizing and alignment. J Shoulder Elbow Surg 2009;18(1): Hughes JS, Morrey BF, King GJ: Unlinked arthroplasty, in Morrey BF, Sanchez-Sotelo J, eds: The Elbow and its Disorders, ed 4. Philadelphia, PA, Saunders Elsevier, 2009, pp Papandrea RF: Hemiarthroplasty of the distal humerus, in Lee DH, Neviaser RJ, eds: Shoulder and Elbow Surgery: Operative Techniques. Philadelphia, PA, Elsevier Saunders, 2011, pp Adolfsson L, Nestorson J: The Kudo humeral component as primary hemiarthroplasty in distal humeral fractures. J Shoulder Elbow Surg 2012; 21(4): Burkhart KJ, Nijs S, Mattyasovszky SG, et al: Distal humerus hemiarthroplasty of the elbow for comminuted distal humeral fractures in the elderly patient. J Trauma 2011;71(3): Heijink A, Morrey BF, Cooney WP III: Radiocapitellar hemiarthroplasty for radiocapitellar arthritis: A report of three cases. J Shoulder Elbow Surg 2008; 17(2):e12-e15. July 2013, Vol 21, No 7 437