Elbow Arthroplasty: Procedure, Benefits, Risks, Recovery and Alternatives

Elbow arthroplasty—commonly known as elbow replacement—is a surgical option for those suffering from severe elbow pain and dysfunction. Advances in prosthesis design and surgical technique have made this procedure a viable solution for various elbow conditions, especially when other treatments have failed. In this article, we break down the procedure, its benefits, potential risks, recovery expectations, and alternative treatments, so you can make an informed decision or simply better understand this life-changing intervention.

Elbow Arthroplasty: The Procedure

Elbow arthroplasty is a specialized orthopedic surgery designed to relieve pain and restore function in damaged elbow joints. It is most often performed for patients with severe arthritis (especially rheumatoid arthritis), complex fractures, or post-traumatic joint damage. The procedure involves replacing the damaged parts of the elbow with artificial implants, which can vary in design and complexity depending on the patient's needs and the surgeon’s preference.

Indication	Implant Type	Surgical Approach	Source
Rheumatoid arthritis, severe trauma	Linked/unlinked prosthesis	Posterior incision, triceps mobilization	2,4,13
Fractures (elderly), ankylosis	Semiconstrained, custom	Posteromedial approach	4,5,13
Severe post-traumatic arthritis	Convertible, interposition	Posterior, "triceps-on" possible	1,13,16
Osteoarthritis, instability	Ulnohumeral, partial	Variable	6,15

Table 1: Key Characteristics of Elbow Arthroplasty Procedure

Types of Elbow Arthroplasty

There are several forms of elbow arthroplasty, tailored to the underlying condition:

• Total Elbow Arthroplasty (TEA): Replacement of both sides of the elbow joint with metal and plastic components, available in "linked" (semi-constrained) or "unlinked" (less constrained) designs. Linked implants offer greater stability, while unlinked devices preserve more bone and soft tissue but require intact ligaments 2,4,15.
• Hemiarthroplasty: Replacement of only one part of the elbow, typically the distal humerus, preserving the patient’s own ulna and radius. This is often considered in complex fractures, especially in elderly patients 16,17,18.
• Interposition Arthroplasty: A salvage procedure using biological tissue (such as Achilles tendon allograft) placed between the joint surfaces, usually for younger, active patients where prosthesis is less desirable 1.
• Partial Arthroplasty: Involves replacing only a portion of the joint (e.g., ulnohumeral arthroplasty), more common for primary osteoarthritis 6.

Surgical Technique Overview

The surgery usually follows these steps:

1. Preparation and Positioning: The patient is positioned to allow full access to the joint, typically supine or lateral decubitus 13.
2. Incision and Exposure: A posterior incision is made, with careful identification and protection of the ulnar nerve. The triceps tendon is mobilized to access the joint surfaces 13.
3. Bone Preparation: The damaged parts of the humerus and ulna are prepared according to the prosthesis design, ensuring anatomical alignment 13.
4. Implant Insertion: Trial and final prosthetic components are placed and checked for stability and range of motion 13.
5. Closure and Postoperative Care: The wound is closed in layers, and a dressing is applied. Early rehabilitation is crucial for optimal functional recovery 5,13.

Patient Selection and Indications

• Ideal Candidates: Patients with end-stage rheumatoid arthritis, elderly individuals with unreconstructable distal humeral fractures, and those with post-traumatic arthritis or ankylosis unresponsive to other treatments 2,3,4,5.
• Contraindications: Active infection, poor bone quality, or severe instability (for certain implant types) 1,15.

Benefits and Effectiveness of Elbow Arthroplasty

Elbow arthroplasty offers substantial pain relief and improved joint function for people with severe elbow problems. When performed in appropriately selected patients, it can transform quality of life—enabling a return to daily activities and even certain forms of employment.

Outcome	Typical Result	Patient Group	Source
Pain Relief	Significant	RA, trauma, OA	3,4,5,11
Range of Motion	97°–129° flexion arc	Most post-surgery	2,3,5,14
Function	MEPS 84–90+	Ankylosis, RA, fracture	3,4,5,11,14
Longevity	77–92% survival at 5–10 years	RA, elderly, trauma	2,3,4,14

Table 2: Typical Benefits and Effectiveness of Elbow Arthroplasty

Pain Relief and Function Improvement

• Pain Reduction: Most patients experience dramatic pain relief after surgery, with mean pain scores dropping to near zero in long-term studies 3,5,11.
• Range of Motion: Flexion-extension arcs typically improve from severely restricted preoperative ranges (sometimes less than 50°) to 97°–129°, enabling essential activities like eating and personal hygiene 2,3,5,14.
• Functional Scores: The Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores show marked improvement—often from poor or fair preoperative ratings to good or excellent postoperatively 4,5,11,14.
• Return to Activity: A substantial proportion of patients return to their previous level of work, especially after ulnohumeral or partial arthroplasties 6.

Longevity and Implant Survival

• Implant Survival: At 5–10 years post-op, survival rates range from 77%–92%, with best results in rheumatoid arthritis and elderly populations 2,3,4,14. Some studies report survival rates up to 20 years, though revision rates increase over time 4,11.
• Complication Rates: Despite good functional outcomes, the rates of revision and complications are higher than in hip or knee replacements 2,4,11,14.

Patient Satisfaction

• Most patients report their elbow as "much better" or "somewhat better" post-surgery, particularly in terms of pain and daily function 1,4,11.

Risks and Side Effects of Elbow Arthroplasty

While elbow arthroplasty can be highly beneficial, it is not without risks. Complications are more frequent than with other major joint replacements, and proper patient selection and postoperative care are essential to minimize adverse outcomes.

Complication	Frequency	Notes	Source
Infection	3–7% (deep), up to 12% (revision)	Higher than hip/knee replacements	8,9,10
Loosening	7–13%	Main cause for revision	2,7,11
Nerve injury	2–5%	Usually ulnar nerve	8,11,16
Periprosthetic fracture	5–15%	Risk increases with trauma history	3,4,8
Mechanical failure	2–10%	Bushing wear, dislocation	4,7,8,14

Table 3: Common Risks and Complications of Elbow Arthroplasty

Infection

• Periprosthetic Joint Infection: The risk is higher than in other joint replacements, with rates up to 3–7% in primary cases and higher in revisions. Staphylococcus species are the most common pathogens 8,9,10. Risk factors include rheumatoid arthritis, obesity, previous elbow surgery, and wound complications 10.
• Management: Infections may require antibiotics, debridement, or even staged revision surgery, which can affect outcomes and function 10.

Mechanical Complications

• Loosening: Aseptic loosening of the implant is the leading cause of revision, seen in 7–13% of cases at long-term follow-up 2,7,11.
• Component Failure: Bushing wear, disassembly, or fracture of the prosthesis may occur, particularly with older or fully constrained designs 4,7,8.
• Dislocation/Instability: More common with unlinked prostheses or in cases with soft tissue deficiency 2,7,15.

Nerve and Soft Tissue Issues

• Nerve Injury: Ulnar nerve palsy or neurapraxia occurs in 2–5% of patients, usually resolving over time but occasionally persistent 8,11,16.
• Triceps Insufficiency: May result in extension weakness if the triceps tendon is not properly repaired 8.

Other Risks

• Periprosthetic Fracture: Can occur during or after surgery, especially in patients with poor bone quality or trauma history 3,4,8.
• Complication Rates Overall: Range from 16%–45%, higher than for other joint arthroplasties 7,9,11.

Recovery and Aftercare of Elbow Arthroplasty

Recovery from elbow arthroplasty involves a coordinated rehabilitation program, careful wound care, and lifestyle adjustments to protect the new joint and maximize function.

Recovery Aspect	Typical Protocol	Expected Duration	Source
Hospital Stay	2–4 days	Variable by patient	13,5
Immobilization	Short (few days to 2 weeks)	Early mobilization preferred	5,13
Rehab Start	Immediate to 2 weeks	Guided by therapist	5,13
Return to Activity	6–12 weeks (light use), 3–6 months (full)	Depends on patient and procedure	5,13
Lifting Restrictions	Often lifelong (<5–10 kg)	To prevent implant loosening	4,15

Table 4: Key Elements of Elbow Arthroplasty Recovery

Immediate Postoperative Care

• Wound Management: Dressings are applied, and close monitoring for infection or hematoma is essential 13.
• Pain Control: Adequate pain management allows early participation in rehabilitation 13.

Rehabilitation Program

• Early Mobilization: Gentle range of motion exercises are usually started within days after surgery to prevent stiffness 5,13.
• Physical Therapy: A structured program is tailored to restore movement and strength while protecting the repair. Compliance is crucial for a good outcome 5.

Activity Limitations

• Lifting Restrictions: Permanent limits on heavy lifting (often 5–10 kg) are recommended to prevent implant loosening or fracture 4,15.
• Return to Work and Sports: Most patients can return to light activities within 6–12 weeks, but high-impact or heavy manual work may not be possible 5,13.

Long-Term Follow-Up

• Regular Checkups: Ongoing clinical and radiographic monitoring is needed to detect early signs of loosening or wear 4,11.
• Patient Education: Understanding the importance of activity modification and early reporting of symptoms is key to long-term success 5.

Alternatives of Elbow Arthroplasty

Not all patients are ideal candidates for elbow arthroplasty. Several alternative treatments should be considered based on the severity of disease, patient age, activity level, and goals.

Alternative	Indication	Outcome Notes	Source
Non-surgical	Early arthritis, mild pain	NSAIDs, therapy, injections	1,15
Interposition Arthroplasty	Young, active, severe arthritis	Partial pain relief, not full function	1
Ulnohumeral Arthroplasty	Primary osteoarthritis	Good motion, pain relief	6
Hemiarthroplasty	Unreconstructable fractures, elderly	Comparable to TEA, similar complications	16,17,18
Radial Head Replacement	Comminuted fractures	Satisfactory in most cases	15

Table 5: Alternatives to Elbow Arthroplasty

Non-Surgical Management

• Medication and Therapy: NSAIDs, physical therapy, and corticosteroid injections remain first-line for early or moderate disease 15.
• Activity Modification: Avoidance of aggravating activities can help reduce symptoms 15.

Joint-Preserving Surgeries

• Interposition Arthroplasty: Uses biological tissue to cushion the joint; considered a salvage option for young, active patients not suitable for TEA. It rarely restores full function and is not recommended in unstable elbows 1.
• Ulnohumeral Arthroplasty: Partial removal of bone spurs to improve motion in primary osteoarthritis. Good outcomes reported with sustained benefit 6.

Partial Joint Replacement

• Hemiarthroplasty: Replacement of only the distal humerus, preserving the patient’s own ulna and radius. Shows similar functional results to TEA in elderly with unreconstructable fractures, though complication rates remain significant 16,17,18.

Other Prosthetic Options

• Radial Head Replacement: Targeted for comminuted radial head fractures or post-traumatic conditions. Satisfactory results in most studies 15.

Conclusion

Elbow arthroplasty is a transformative procedure for patients suffering from debilitating elbow conditions, especially when conservative treatments have failed. While the surgery offers excellent pain relief and improved function, it comes with higher complication and revision rates than other joint replacements. Careful patient selection, surgical expertise, and adherence to postoperative protocols are vital for optimal outcomes. Several surgical and non-surgical alternatives exist, each with distinct advantages and limitations.

Key Takeaways:

• Elbow arthroplasty is primarily indicated for severe arthritis, complex fractures, and post-traumatic damage unresponsive to other treatments.
• The procedure significantly relieves pain and restores function, especially in older adults and those with rheumatoid arthritis.
• Risks include infection, implant loosening, nerve injury, and periprosthetic fracture—complication rates are higher than for hip or knee replacements.
• Postoperative recovery relies on early rehabilitation and lifelong activity modifications to protect the implant.
• Alternatives such as interposition arthroplasty, hemiarthroplasty, and radial head replacement may be more appropriate for certain patients.

Understanding the spectrum of options and their associated benefits and risks allows patients and clinicians to choose the most suitable path to restored elbow function and quality of life.