Voloshin, J Shoulder Elbow Surg 2011 - Complications of Total Elbow Replacement: A Systematic Review - Article Summary

Complications of Total Elbow Replacement: A Systematic Review

Voloshin, Morrey, et al.·J Shoulder Elbow Surg·2011·303 citations·Systematic review

This systematic review of 64 studies and 2,938 total elbow arthroplasties (TEAs) quantifies complication rates by prosthesis type and surgical indication. It addresses an 18-year gap since the prior major TEA complication review by Gschwend et al. The central question: have modern implants and techniques reduced the historically high TEA complication burden?

Key Findings

The overall TEA complication rate from 1993–2009 was 24.3% — substantially lower than the 43% reported from prior literature (1986–1992), though the two methodologies are not directly comparable. The most common complications were loosening, instability, and deep infection. The same triad identified in prior reviews, just less frequent.
Indication drives risk: post-traumatic arthritis carried the highest complication rate at 37.5%, significantly higher than acute distal humerus fractures at 21.5% (P < .05). Inflammatory arthritis fell in between at 24.3%. Before selecting an implant, the underlying diagnosis is one of the strongest predictors of outcome.
Unlinked prostheses had a dislocation/subluxation rate of 4.9% vs 1.4% for linked designs (P < .01). A tradeoff for the lower bone-cement interface stress that makes unlinked designs appealing. If an unlinked TEA dislocates and soft tissue reconstruction fails, revision to a semi-constrained device is the most reliable salvage option.
Linked prostheses had higher combined radiographic and clinical loosening (13.7% vs 10.1% for unlinked, P < .05), though clinical loosening alone was equivalent at ~5.2% for both. The linked loosening difference is confounded by selection bias. Linked devices are used preferentially in more difficult traumatic cases.
Linked designs carry unique mechanical failure modes: bushing wear in 2.3% and disassembly in 1.7%. Disassembly is treated with bushing exchange alone if components are well-fixed, not full revision.
Routine ulnar nerve transposition did not significantly reduce ulnar nerve complication rates (2.0% with transposition vs 3.2% without, P > .5). The decision to transpose should be based on intraoperative assessment, not dogma.
Deep infection occurred in 3.3%. Higher than for hip or knee arthroplasty. The elbow's subcutaneous position, thin soft tissue envelope, and the immunosuppressed status of many TEA patients (DMARDs for RA) are the primary reasons this rate exceeds other large joint replacements.

Board PearlTotal elbow arthroplasty carries a 24% overall complication rate — far higher than hip or knee replacement — and post-traumatic arthritis carries the worst prognosis at 37.5%.

Supplemental

Complications of Total Elbow Replacement: A Systematic Review

Voloshin, Morrey, et al.J Shoulder Elbow Surg2011303 citationsSystematic review