SURGICAL TECHNIQUE
Total Elbow Arthroplasty: Surgical Technique
James B. Bennett, MD, Thomas L. Mehlhoff, MD
Implant arthroplasty about the elbow using custom metal components for the distal humerus
and proximal ulna was developed in the 1960s. Before this time, the only salvage procedures
available for destructive joint disease about the elbow were resection arthroplasty, fascial
interposition arthroplasty, or elbow arthrodesis. Today, many total elbow arthroplasty
designs are available and used throughout the world. The Coonrad-Morrey total elbow
prosthesis (Zimmer, Warsaw, IN) is the most widely used implant for elbow arthroplasty in
the United States and has been chosen for discussion in this surgical technique article. (J
Hand Surg 2009;34A:933–939. Copyright © 2009 by the American Society for Surgery of
the Hand. All rights reserved.)
Key words Arthritis, arthroplasty, elbow, surgical technique.
began in 1972 with
T
OTAL ELBOW ARTHROPLASTY
the introduction of the Dee prosthesis.1 This
implant was a constrained articulated prosthesis
requiring methyl methacrylate cement and marked bone
resection. A high failure rate from loosening led to the
development of semiconstrained and nonconstrained
prosthetic implants to reduce bone resection and dis-
tribute force about the implant to reduce loosening. Dr.
Ralph Coonrad introduced a total elbow arthroplasty
system requiring less bone resection and less biome-
chanical alteration of the elbow joint than did the Dee
prosthesis.2 The Coonrad design was further modified
at the Mayo Clinic in 1978 under the direction of Dr.
Bernard Morrey. The implant was a semiconstrained
device that would permit 7° to 10° of hinged laxity,
corresponding with the normal elbow. In addition, an
anterior flange was added to the humeral component for
fixation with a bone graft to improve anteroposterior
stress forces and torsional rotation to increase the sta-
bility and longevity of the implant. Most recently, the
From the Baylor College of Medicine, Houston, TX; University of Texas Medical School at Houston,
Houston, TX; and the Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX.
The authors thank Mike de la Flor for the illustrations and Daniel P. O’Connor and the Joe W. King
Orthopedic Institute for assistance with the manuscript.
Received for publication December 11, 2008; accepted in revised form February 16, 2009.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Corresponding author: James B. Bennett, MD, Fondren Orthopedic Group, 7401 S. Main Street,
Houston, TX 77030-4509; e-mail: james_bennett@fondren.com.
0363-5023/09/34A05-0023$36.00/0
doi:10.1016/j.jhsa.2009.02.021
Surgical Technique
C-ring locking device of the Coonrad-Morrey implant
(Zimmer, Warsaw, IN) has been replaced with an axis
pin locking device to provide a more secure assembly
of the components.
Newer designs and surgical techniques have notably
decreased the earlier high complication rate for total
elbow arthroplasty. Complication rates have dropped
from 50% to an acceptable 10% in most series. Reports
of total elbow arthroplasty in rheumatoid arthritis pa-
tients have shown a 92% survival rate at 10 years after
replacement.
INDICATIONS
The goal of total elbow arthroplasty is to decrease pain
and to restore a reasonable arc of motion to the elbow.
The primary indication for total elbow arthroplasty is in
the rheumatoid arthritis patient, who is preferably 65
years or older with a low level of activity. Relative
indications for total elbow arthroplasty now include
patients with osteoarthritis and traumatic arthritis as
well, as greater experience has been accumulated.3,4
Total elbow arthroplasty is also indicated for the acute
treatment of highly comminuted fractures of the distal
humerus in the older patient, where open reduction and
internal fixation may not be possible.5 Finally, total
elbow arthroplasty may be indicated for reconstruction
of bone loss in tumor cases, often requiring a custom
elbow implant.
CONTRAINDICATIONS
Absolute contraindications include active infection,
open wound with skin and soft tissue defect, and neu-
©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 933
 934 TOTAL ELBOW ARTHROPLASTY
romuscular paralysis. Relative contraindications in-
clude the noncompliant patient, the heavy laborer, mas-
sive bone loss, or a functional, nonpainful arthrodesis.
Every patient who has total elbow arthroplasty must be
willing to accept a lifetime 5-lb lifting restriction for the
extremity.
SURGICAL ANATOMY
A variety of surgical approaches have been de-
scribed to expose the elbow joint for total elbow
arthroplasty. A longitudinal posterior incision
through the skin with subcutaneous tissue flaps is
most often favored to avoid skin necrosis and
injury to the cutaneous nerves. Knowledge of the
neurovascular anatomy is essential to avoid nerve
injury, especially to the ulnar nerve. The key to
Surgical Technique
exposure centers on the triceps tendon and the
olecranon. Currently favored exposures include
the triceps splitting approach, leaving the triceps in
continuity with the retinaculum over the proximal
ulna, or the triceps “on” approach using lateral and
medial fascial incisions to expose the elbow joint
for arthroplasty without detaching the triceps.
Small intramedullary canals due to rheumatoid ar-
thritis or malalignment due to previous trauma
present surgical challenges, requiring proper pre-
operative evaluation and preparation.
SURGICAL TECHNIQUE
Surgery is performed under general anesthesia with an
optional brachial plexus block catheter positioned in the
preoperative holding area. The patient is placed supine
on the operating table with a rolled sheet or sandbag
under the shoulder of the elbow being operated on. The
arm is draped free and placed across the chest. It is
important that the elbow can be flexed fully during the
surgical procedure, especially for preparation of the
ulnar canal. The patient receives an appropriate intra-
venous antibiotic before the skin incision. A straight
longitudinal incision is placed over the posterior aspect
of the elbow. The skin incision does not need to curve
around the olecranon tip. Full-thickness subcutaneous
flaps are elevated off the fascia of the triceps. With
extensive elevation, the flaps will retract back without
the need for large retractors.
The ulnar nerve is identified in the upper arm and
then decompressed through the cubital tunnel by releas-
ing the fascia in a proximal to a distal direction. If
necessary, the ulnar nerve can be mobilized for anterior
subcutaneous transposition at the end of the procedure.
Bipolar electrocautery and loupe magnification increase
the safety for surgery about the ulnar nerve.
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The elbow joint is then exposed with a triceps split-
ting or a Bryan-Morrey triceps reflecting approach. The
triceps tendon is incised longitudinally. The attachment
of the tendon to the proximal ulna is carefully reflected
from the medial and lateral aspects of the ulna and kept
in continuity with the forearm fascia extending to the
proximal ulna. Dissection then continues onto the epi-
condyles, releasing the lateral collateral ligament and
then the medial collateral ligament from their distal
humerus attachments. Finally, the anterior capsule is
released from the distal humerus to fully expose the
elbow joint and release any flexion contracture. Dissec-
tion must stay strictly on the anterior distal humerus to
avoid injury to the anterior neurovascular structures.
More proximal exposure of the humerus for revision
cases or allograft struts will require identification and
protection of the radial nerve in the upper arm as well.
After release of the soft tissues, the elbow joint can be
easily dislocated, allowing for bone preparation. Radial
head resection may be performed to increase or im-
prove exposure.
The intramedullary canal size of the ulna limits the
size of the implant more often than does the humeral
canal. For this reason, we recommend preparation of
the ulna first. The olecranon tip is removed with the saw
to improve straight-line access to the canal. A 4.0-mm
burr on a long handle is used to penetrate the subchon-
dral bone of the coronoid and expose the canal. The
ulnar canal is identified by inserting progressively
larger curettes or awls. The pilot rasp is then inserted by
hand followed by light hammer taps on the rasp handle.
Proximal bone may need further removal with the burr
to allow proper seating of the rasp. Orientation of the
ulnar rasp handle is perpendicular to the flat plane of the
posterior olecranon. The posterior cortex is more vul-
nerable to penetration than is the anterior cortex during
preparation. Great care should be taken to avoid pene-
tration of the dorsal cortex of the ulna at the tip of the
rasp. The starter rasp is then used to enlarge the in-
tramedullary canal, followed by the small and regular
rasp, if indicated. The correct trial ulnar component is
inserted. The center ring of the ulnar component should
replicate the normal anatomic axis of the greater sig-
moid notch. If not, further preparation of the bone
should be performed until properly seated.
Preparation of the humerus begins by resecting disks
of bone from the midportion of the trochlea as a rough
cut. A series of disks is removed, one of which will fit
under the anterior flange as a bone graft. The intramed-
ullary canal of the humerus is then identified with a
curette or awl followed by the long-handled burr. The
T-handled humeral alignment guide is then placed into
 TOTAL ELBOW ARTHROPLASTY 935

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

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

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 936 TOTAL ELBOW ARTHROPLASTY
Surgical Technique
FIGURE 2: Illustration for placement of the axis locking pins.
humeral and ulna components are matched at the axis
pin coupling device so that an extrasmall ulna may
articulate with a small or standard humeral component.
Standard cement techniques are used with or without
antibiotics, based on the surgeon’s preference. Cement
restrictors, bone plug, or even gel foam can be placed
into the humerus to improve cement pressure and limit
cement into the proximal humerus. The actual implants
are placed into the ulna and then the humerus to ensure
good fit before cementing and connecting. At this time,
the anterior flange bone graft is selected from the bone
disks previously cut from the trochlea. The anterior
humeral cortex is rasped or burred to encourage bone
graft healing once graft position is determined.
The implants may be inserted and cemented sepa-
rately or simultaneously in conjunction with the locking
axis pin mechanism. The cement is placed into the
humerus in a viscous state with the cement gun, fol-
lowed by pressure packing. Cement is then inserted into
the ulna canal. Extra cement is placed at the tip of the
ulnar component. The ulnar component is then seated.
The excess cement is removed from the ulna. Cement is
then placed on the tip of the humeral component. The
humeral component is partially seated until the anterior
flange grasps the anterior bone graft. The ulnar compo-
nent is then aligned with the humeral component (Fig.
2). The axis locking pins are then placed and snapped
together. The hollow outer axis pin is coupled with the
solid internal axis pin across the articulated humeral and
ulna components with a click at engagement. The driver
is then positioned on the humeral component, and a
mallet is used to drive the humeral component into the
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humerus until fully seated, locking the anterior bone
graft beneath the flange against the anterior humeral
cortex. Again, excess cement is removed. The elbow is
then held in extension until the cement has hardened.
Premature flexion of the elbow while the cement is soft
may result in pistoning of the ulnar or humeral compo-
nent and cement loosening (Fig. 3).
Intraoperative x-rays are then taken in both antero-
posterior and lateral views to ascertain position for the
implant and to exclude any problems, such as cortex
perforation or periprosthetic fracture. If a bone defect is
detected, bone grafting, plating, or allograft strut may
need to be considered.
Reattachment of the triceps is critical to functional
recovery. The triceps is reattached to the proximal ulna
with large nonabsorbable sutures through drill holes in
bone (Fig. 4). The longitudinal component of the triceps
exposure is repaired with side-to-side sutures. The tour-
niquet is released. Pulsed lavage may be used with or
without antibiotics. The wound is closed over a Hemo-
vac drain (BARD, Covington, GA) in standard fashion.
The collateral ligaments do not need specific repair due
to the semiconstrained design of the implant. Any re-
sidual impingement of the ulna on the distal humerus in
extension should be addressed with bone removal if
needed. A prominent medial epicondyle might be
smoothed with the saw as well. The decompressed
ulnar nerve may be left in situ or anterior transposed
subcutaneously if indicated. The subcutaneous tissue is
approximated over the deeper structures and the skin
well-aligned with staples for a strong, well-sealed clo-
sure. Sterile dressings are applied, followed by an an-
terior and/or posterior fiberglass splint with the elbow in
30° to full extension. The arm is elevated postopera-
tively during hospitalization.
REHABILITATION
The patient is admitted to the hospital for appropriate
pain and medical management. Rheumatoid arthritis
patients often stay for 2 to 3 days, given their limited
mobility. The Hemovac drain is monitored for 24 to 36
hours. Pain is controlled with a brachial plexus block
catheter, followed by oral medication. Hand and shoul-
der function is encouraged immediately or as soon as
the block has dissipated.
The wound is allowed to heal before initiating elbow
range of motion. At 7 to 10 days, the postsurgical splint
and dressings are removed. An Orthoplast posterior
extension splint (Johnson & Johnson, Langhorne, PA)
is fabricated to allow for gentle active range of motion
but no triceps muscle resistance. At 2 weeks, the skin
staples are removed as dictated by the condition of the
 TOTAL ELBOW ARTHROPLASTY 937

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

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

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 938 TOTAL ELBOW ARTHROPLASTY
Surgical Technique
FIGURE 5: A Preoperative radiograph showing periprosthetic fracture. B Postoperative radiograph showing cortical strut allografts
and unicortical locking plate.
skin and soft tissues. Range of motion is progressed as
a home program, emphasizing extension and flexion. A
hinge brace may be used to support the elbow until the
flexor and extensor origins have healed to the condyles.
The patient is advised not to lift more than 1 lb during
the first 3 months after surgery and will observe a 5-lb
permanent lifetime lifting restriction for the extremity.
Appropriate x-rays are performed at 3 months, 6
months, and 1 year postoperatively to evaluate for im-
plant position, radiolucent lines, or periprosthetic
changes in the bone. Our patients are reminded to
consider antibiotic prophylaxis for dental, gastrointesti-
nal, or urologic procedures.
PEARLS AND PITFALLS
● Rheumatoid elbows, especially in juvenile rheu-
matoid arthritis patients, may have very small ul-
nar canals that will limit implant size, often requir-
ing the extrasmall component. Be prepared for
intramedullary canal problems that might result
from posttraumatic changes as well.
● Rheumatoid arthritis patients on anti–tumor necro-
sis factor drugs such as adalimumab (Humira; Ab-
bott Laboratories, North Chicago, IL), infliximab
(Remicade; Centocor, Inc., Malvern, PA), and et-
anercerpt (Enbrel; Amgen, Inc., Thousand Oaks,
CA) are at higher risk for infection, including late
infection. Consider vancomycin or tobramycin an-
JHS 䉬 Vol A, May–June 
tibiotic in the cement for even primary cases. Pre-
operative skin preparation with hexachlorophene
soap (pHisoHex; Sanofi-Aventis, Bridgewater, NJ)
for 3 days or 1 week before surgery is recom-
mended.
● During preparation of the ulna, continue to work
the rasp parallel to the dorsal cortex to avoid
malalignment or posterior bone penetration at the
tip of the implant.
● The extrasmall ulnar component is available in a
longer length and can be cut with a bolt cutter if
necessary for proper length fit.
● The humeral condyles can be sacrificed if fractured
or nonunited. The humerus can be shortened to
achieve full extension if necessary, especially in
posttraumatic situations.
● The anterior bow of the humerus should be re-
spected if a long-stem humeral implant is being
used. The plate bender may be necessary to give a
slight contour to a long stem to accommodate any
anterior humeral bow.
● Trial fit the actual components before cementing.
A slower-setting cement may be helpful to insert
and seat both components simultaneously.
● The Achilles’ tendon allograft is used for the sal-
vage of triceps rupture or insufficiency.
● Periprosthetic fractures with a well-fixed compo-
nent may require cortical allograft struts and band-
 TOTAL ELBOW ARTHROPLASTY
FIGURE 6: Postoperative A anteroposterior and B lateral
radiographs for the patient in Figure 1 showing the total elbow
arthroplasty.
ing for reconstruction.6,7 Periprosthetic fractures
with a loose component require revision with a
longer stem, as well as cortical allograft struts and
banding. Surgery for a loosened component before
periprosthetic fracture will require revision of the
component, as well as possible impaction bone graft-
ing for intramedullary bone loss.8 Unicortical locking
plates and screws may also secure fixation (Fig. 5).
COMPLICATIONS
Acute, subacute, or chronic infection is a primary con-
cern. Ulnar neuritis symptoms have been minimal with
JHS 䉬 Vol A, May–June 
939
proper decompression of the ulnar nerve. Triceps insuf-
ficiency can occur acute or late and may require recon-
struction with an Achilles’ tendon allograft. Peripros-
thetic loosening and periprosthetic fracture are known
complications, requiring reconstruction with strut allo-
grafts. Instability of the prosthetic components can be a
problem if the locking pin fails or there is abnormal
polyethylene wear of the bushings. Revision axis pin
and bushings sets are available.9
Total elbow arthroplasty has become a successful
reconstruction for painful destructive arthritis about the
elbow with an acceptable complication rate. Patients
must be willing to accept a lifetime 5-lb lifting restric-
tion for the extremity to ensure longevity and ultimate
satisfactory function for the total elbow replacement
(Fig. 6).
Surgical Technique
REFERENCES
1. Dee R. Total replacement arthroplasty of the elbow for rheumatoid
arthritis. J Bone Joint Surg 1972;54B:88 –95.
2. Coonrad RW. Seven-year follow-up of Coonrad total elbow replace-
ment. IN: Inglis AE, ed. Upper extremity joint replacement (sympo-
sium on total joint replacement of the upper extremity, 1979). St.
Louis: C.V. Mosby Co., 1982:91–99.
3. Antuña SA, Morrey BF, Adams RA, O’Driscoll SW. Ulnohumeral
arthroplasty for primary degenerative arthritis of the elbow: long-
term outcome and complications. J Bone Joint Surg 2002;84A:
2168 –2173.
4. Cheung EV, Adams R, Morrey BF. Primary osteoarthritis of the
elbow: current treatment options. J Am Acad Orthop Surg 2008;16:
77– 87.
5. Kamineni S, Morrey BF. Distal humeral fractures treated with non-
custom total elbow replacement. Surgical technique. J Bone Joint
Surg 2005;87A(Suppl Pt 1):41–50.
6. Athwal GS, Morrey BF. Revision total elbow arthroplasty for pros-
thetic fractures. J Bone Joint Surg 2006;88A:2017–2026.
7. Sanchez-Sotelo J, O’Driscoll S, Morrey BF. Periprosthetic humeral
fractures after total elbow arthroplasty: treatment with implant revi-
sion and strut allograft augmentation. J Bone Joint Surg 2002;84A:
1642–1650.
8. Loebenberg MI, Adams R, O’Driscoll SW, Morrey BF. Impaction
grafting in revision total elbow arthroplasty. J Bone Joint Surg 2005;
87A:99 –106.
9. Lee BP, Adams RA, Morrey BF. Polyethylene wear after total elbow
arthroplasty. J Bone Joint Surg 2005;87A:1080 –1087.