Abstract
Purpose
Total elbow arthroplasty (TEA) can be used to treat both distal humerus fractures and arthritis of the elbow joint. This study aimed to compare complication, reoperation, and revision rates following TEA between these two indications.
Methods
A retrospective review of TEA was performed within a single large orthopedic practice. All patients who had undergone a TEA between 2016 and 2020, yielding 96 TEA cases for analysis, were queried. TEA cases were categorized by indication into arthritis diagnoses (AX) and distal humerus fractures (FX). Demographic and clinical data, complications, reoperations, and revisions were recorded over a 4-year follow-up period. Kaplan-Meier implant survival and multivariable analyses were performed.
Results
A total of 96 TEAs (54 AX and 42 FX) with a mean age of 70.3 ± 12.4 years were included, among which 78% (75/96) were women. Patients in the AX group (64.8 ± 10.9 years) were younger than those in the FX group (77.5 ± 10.5 years). The overall TEA complication rate was 42%, and the reoperation rate was 23%. The AX group had higher rates of complications (44% vs 38%) and reoperations (30% vs 14%) than the FX group. Overall, men had higher rates of both complications (76% vs 33%) and reoperations (43% vs 19%) than women. Survival analysis for any reoperation at 4 years showed TEA for FX having higher survival (86%) than TEA for AX (70%). On multivariable analysis, only being male was associated with more complications, but the model was unstable because of low sample size.
Conclusions
Almost one-half of TEA patients experienced complications and approximately one in four required reoperation within 4 years postop. Total elbow arthroplasty remains associated with substantial complication and reoperation rates. Surgical indication and gender may influence postoperative TEA outcomes.
Type of study/level of evidence
Prognosis IV.
Keywords: Distal humerus fracture, Elbow arthritis, Postoperative complications, Reoperation, Total elbow arthroplasty
Total elbow arthroplasty (TEA) is a surgical procedure that involves the replacement of the distal humerus, proximal ulna, and sometimes the proximal radius, with prosthetic components. TEA is most commonly indicated for conditions such as rheumatoid arthritis, osteoarthritis, post-traumatic arthritis, and distal humerus fractures.1,2 When successful, TEA can effectively relieve pain and restore elbow function and range of motion.1
The use of both primary and revision TEA is expected to increase, especially as the population both grows and lives longer.3 This projected rise highlights the need for improved understanding of the complications associated with primary TEA, their relationship to subsequent reoperation and revision procedures, as well as how the underlying indication for surgery may affect these outcomes.
Over the years, TEA has had improvements in implant design, refinement of surgical approaches such as triceps-sparing techniques, and advances in perioperative protocols, which have enhanced outcomes in many patient populations.4,5 Although TEA is a reliable surgery with favorable short-term outcomes, even modern prosthetic implants demonstrate notable complication rates ranging from 11% to 38%, with common issues including infection, ulnar nerve injury, periprosthetic fracture, triceps rupture/insufficiency, limited range of motion (ROM), and implant loosening.6 TEAs have also been reported to have reoperation rates as high as 41% over a mean follow-up range of 6.1 years.7 The relatively high rates of TEA complications and reoperations make it worthwhile to explore predictors, such as operative indication, for these negative occurrences, focusing on improving patient selection and surgical planning. Additionally, prior studies in hip and knee arthroplasty have shown sex-based differences in complication and reoperation rates, suggesting that similar patterns may be found in TEA.8, 9, 10
The main objective of this study was to compare the complication rate in patients undergoing TEA for arthritic conditions versus acute traumatic injuries. Secondary outcomes included reoperation and revision rates, the timing of these events, type of reoperation, and limited ROM. This study hypothesized that patients in the arthritis group would experience higher rates of complications and reoperation rates compared to those in the trauma group.
Methods
Following institutional review board approval, the electronic medical record database of a single large orthopedic practice was queried to identify all patients who underwent TEA from 2016 through 2020, a 5-year period, using the corresponding TEA CPT code 24363. A retrospective chart review was then performed to collect detailed demographic and clinical information. Inclusion criteria were all TEAs performed for either arthritis (AX), including rheumatoid, osteoarthritis, or post-traumatic arthritis, versus acute distal humerus fracture (FX). Exclusion criteria included patients undergoing TEA for any other indications, patients with less than 4 years of follow-up, and those with incomplete documentation of perioperative events.
Patient charts were analyzed starting from the date of the TEA until at least 4 years after surgery, or until the date of TEA revision surgery if one occurred. The 4-year follow-up period was chosen because this represented the maximum uniform interval available, with the latest surgeries performed in 2020 and data collection being finalized in 2024. Chart data were collected focusing on the date and type of complications, reoperations, and revisions. Additionally, the indication for TEA and limitations in ROM were recorded. All collected data were cross-referenced with the initial query to ensure consistency. Patient comorbidities were recorded using International Classification of Diseases (ICD) codes. In cases of missing or ambiguous information, data were verified with operative notes and surgeon documentation.
The initial query identified 123 individual TEA cases performed during the specified time period. Upon manual review of the query, 24 cases were excluded because of being revision TEAs, missing records, or having incomplete data. An additional three cases (aseptic bone necrosis, acute fixation failure, and distal humoral neoplasm) were excluded following individual chart review as they did not meet the operative indication and stratification into AX or FX groups, resulting in a final cohort of 96 TEAs (Fig. 1).
Figure 1.
Screening flow chart: The screening process to achieve the final TEA analytic cohort using a series of queries and chart review steps to adhere to the inclusion and exclusion criteria.
Complications were defined as any adverse postoperative event documented in the chart. Reoperation was defined as any surgical procedure involving the same elbow on which the primary TEA was performed. Revision was defined as replacement of the entire TEA prosthesis or one or more of its components (humeral and/or ulnar) as documented in the medical record. Since this study relied on revision of the components as a measure of implant failure, it is likely only a minimum estimate of the true rate as patients that may meet the indications for revision do not undergo treatment. Reoperations were further grouped as component-related procedures (CR) (eg, revision surgery, hardware removal, open reduction internal fixation), or component-sparing procedures (CS) (eg, heterotopic ossification excision, triceps repair, bursectomy, ulnar nerve decompression, irrigation, and debridement). This was performed to distinguish between procedures involving prosthetic components, which may reflect implant-related failure, and those addressing soft tissue or nonimplant-related issues, which may represent functional or biological complications.
The primary outcome of this study was the overall complication rate following TEA. Secondary outcomes included reoperation and revision rates, the timing of these events, type of reoperation (CR vs CS), and the presence or absence of limited ROM, defined as measuring outside of 30° extension and 120° flexion. Bivariate analysis was initially performed to screen for potential predictor variables. Multivariable logistic regression was then performed to assess predictors of complications and reoperations (Table S1, available online on the Journal’s website at https://www.jhsgo.org). Welch's T-tests or Mann-Whitney U tests were used for comparisons between two groups and ANOVA or Kruskal-Wallis tests were applied for comparisons among three or more groups. Chi-square or Fisher exact tests were used to compare categorical data. Demographic variables, including sex, age, and body mass index (BMI) were included as covariates in the multivariable analyses to assess potential associations with complications and reoperations. Hand dominance and patient activity level were not available in a standardized format and were therefore not included as covariates to avoid misclassification bias and model overfitting given the limited number of outcome events. Variables were selected a priori based on clinical relevance, and no forward or backward selection techniques were applied. Given the limited number of events, control for multiple confounders was not possible, and results should be interpreted accordingly. A P < .05 was considered significant. Survival analysis was performed using Kaplan-Meier curves looking at reoperations. Finally, a post hoc power analysis was performed to evaluate the viability of the statistical conclusions and the impact of the low sample size on the statistical power of the study (Table S2, available online on the Journal’s website at https://www.jhsgo.org).
All procedures were performed by 16 fellowship-trained hand surgeons at a single academic practice throughout the study period. While consistent perioperative protocols were followed, surgical approach and implant selection were based on individual surgeon choice and were not standardized across the cohort, with both triceps-sparing and triceps-splitting approaches used. Postoperative rehabilitation generally included a short period of immobilization, followed by progressive ROM and strengthening under the guidance of qualified therapists.
Results
Patient characteristics and surgical indications
The 96 TEAs were performed on 94 patients, with two patients undergoing bilateral procedures. All analyses were based on the 96 individual TEAs of which 75 were performed in females (78%) and 21 in males (22%). The mean age at the time of surgery was 70.3 ± 12.4 years (31−95; females: 70.4 ± 12.5; males: 70.1 ± 12.2).
The AX group had 54 (56%) TEAs while the FX group had 42 (44%). Within the AX group, there were 22 (41%) performed for rheumatoid arthritis, 20 (37%) for osteoarthritis, and 12 (22%) for post-traumatic arthritis. Patients in the AX group were significantly younger (64.8 ± 10.9 vs 77.5 ± 10.5, P < .05). The proportion of women was similar in both groups (AX: 78%; FX: 79%). The mean BMI across the cohort was 27.5. Comorbid conditions are shown in Figure 2.
Figure 2.
Percent of total TEAs with preoperative comorbidities.
Primary outcome—complications
At least one complication occurred in 40 of 96 (42%) TEAs, with the AX group having 24 of 54 (44%) and the FX group 16 of 42 (38%). Specific complication data are listed in Table 1.
Table 1.
Number of TEAs Experiencing a Complication Based on Indication
| Category∗ | Total TEAs (n = 96) | AX (n = 54) | FX (n = 42) | P† |
|---|---|---|---|---|
| Anycomplications | 40 (42%) | 24 (44%) | 16 (38%) | .677 |
| Ulnar neuropathy | 16 (17%) | 10 (19%) | 6 (14%) | .783 |
| Infection | 9 (9%) | 6 (11%) | 3 (7%) | .727 |
| Triceps tendon insufficiency | 9 (9%) | 9 (17%) | 0 (0.0%) | <.05 |
| Hematoma | 7 (7%) | 4 (7%) | 3 (7%) | >.99 |
| Implant loosening | 5 (5%) | 3 (6%) | 2 (5%) | >.99 |
| Periprosthetic fracture | 4 (4%) | 2 (4%) | 2 (5%) | >.99 |
| Heterotopic ossification | 3 (3%) | 0 (0%) | 3 (7%) | .080 |
| Olecranon bursitis | 3 (3%) | 2 (4%) | 1 (2%) | >.99 |
| Radial neuropathy | 2 (2%) | 1 (2%) | 1 (2%) | >.99 |
TEAs experiencing specific complications within at least 4 years of surgery, stratified by operative indication of AX or FX. Complication categories are not mutually exclusive, as some TEAs experienced more than one complication.
Statistical comparisons between the AX and FX groups were performed using chi-square or Fisher exact tests, with significance defined as P < .05. Because of low sample size, underpowering was present.
Triceps tendon insufficiency was significantly more common in the AX group (17% vs 0%, P < .05), but it should be noted that underpowering was found. Because of the analysis focusing on the number of TEAs experiencing a complication, rather than raw complication numbers, complication categories cannot be totaled as there were individual TEAs that experienced multiple complications. Figure 3 shows the complication type percentage makeup of the 40 TEAs that had experienced at least one complication. A limited ROM was noted in 17 of 96 TEAs (18%) of which 11 (20%) were in the AX group and 6 (14%) in FX group (P = .613).
Figure 3.
Breakdown of TEAs experiencing a complication by complication type: percentage of TEAs with each complication type within the total number of TEAs that experienced at least one complication (n = 40), stratified by operative indication of AX versus FX. Complication categories are not mutually exclusive, as some TEAs experienced more than one complication.
Secondary outcomes—reoperations and revisions
Twenty-two TEAs (23%) required reoperation, with the AX group having 16 of 54 (30%) and the FX group 6 of 42 (14%). Revision TEA was performed in six cases (6%), three per group. Specific reoperation and revision data are listed in Table 2. Reoperation numbers cannot be totaled. Figure 4 shows the reoperation type makeup of the 22 TEAs that had experienced at least one reoperation.
Table 2.
Number of TEAs Experiencing a Reoperation Based on Indication
| Reoperation Type∗ | Total TEAs (n = 96) | AX (n = 54) | FX (n = 42) | P† |
|---|---|---|---|---|
| Any reoperation | 22 (23%) | 16 (30%) | 6 (14%) | .126 |
| Irrigation and debridement | 7 (7%) | 5 (9%) | 2 (5%) | .463 |
| Revision arthroplasty | 6 (6%) | 3 (6%) | 3 (7%) | >.99 |
| Ulnar nerve procedures | 5 (5%) | 4 (7%) | 1 (2%) | .382 |
| Triceps repair | 4 (4%) | 4 (7%) | 0 (0%) | .129 |
| Bone resection | 3 (3%) | 3 (6%) | 0 (0%) | .254 |
| Open reduction internal fixation | 2 (2%) | 1 (2%) | 1 (2%) | >.99 |
| Hardware removal | 2 (2%) | 1 (2%) | 1 (2%) | >.99 |
| Bushing exchange | 2 (2%) | 2 (4%) | 0 (0%) | .503 |
| ABX spacer placement | 2 (2%) | 1 (2%) | 1 (2%) | >.99 |
| Contracture release | 1 (1.0%) | 1 (2%) | 0 (0%) | >.99 |
TEAs experiencing specific reoperations within at least 4 years of surgery, stratified by operative indication of AX or FX. Reoperation categories are not mutually exclusive, as some TEAs experienced more than one reoperation.
Statistical comparisons between the AX and FX groups were performed using chi-square or Fisher exact tests, with significance defined as P < .05. Because of low sample size, underpowering was present.
Figure 4.
Breakdown of TEAs experiencing a reoperation by reoperation type: percentage of TEAs with each reoperation category within the total number of TEAs that experienced at least one reoperation (n = 22), stratified by indication of AX versus FX. Reoperation categories are not mutually exclusive, as some TEAs experienced more than one reoperation.
Reoperation categorization showed eight TEAs having CR procedures and 18 having CS procedures, with four elbows undergoing both types of interventions. Because of this overlap, the CR and CS TEA categories cannot be totaled. Specific reoperation category data broken down by AX versus FX are listed in Table 3. CS reoperations were significantly more common in the AX group (28% vs 7%, P < .05), but it should be noted that underpowering was found.
Table 3.
Number of TEAs With Component-Sparing Versus Component-Related Reoperations and Time Until First Reoperation
| Category∗ | Total TEAs (n = 96) | AX (n = 54) | FX (n = 42) | P† |
|---|---|---|---|---|
| Any reoperation | 22 (23%) | 16 (30%) | 6 (14%) | .126 |
| Component-sparing | 18 (19%) | 15 (28%) | 3 (7%) | <.05 |
| Component-related | 8 (8%) | 4 (7%) | 4 (10%) | .726 |
| Time to first reoperation (d) | 275 ± 310 | 303 ± 348 | 201 ± 175 | .914 |
| Time to revision (d) | 541 ± 334 | 662 ± 428 | 420 ± 227 | .450 |
Number and percentage of TEAs undergoing component-sparing (CS) versus component-related (CR) reoperations within at least 4 years of surgery, stratified by indication of AX versus FX. The CS and CR categories are not mutually exclusive, as some TEAs experienced both categories of reoperation. Mean time in days until first reoperation, first CS procedure, and first CR procedure is also reported.
Statistical comparisons performed using chi-square or Fisher exact tests, as well as Welch's T-tests or Mann-Whitney U tests, with significance defined as P < .05. Because of low sample size, underpowering was present.
Timing of reoperations and revisions
The mean time to first reoperation was 275 days across all TEAs while the mean time to revision surgery was 541 days. The FX group showed earlier average times until first reoperation and revision though this was not statistically significant (Table 3). Within the whole TEA group, the time to first CS procedure averaged 281 days, while the CR procedure was 552 days. The AX group's mean time to first CS procedure was 315 days, and to first CR procedure was 774 days. In the FX group, the mean times were 110 days and 331 days, respectively.
Survivorship
TEA for FX showed higher implant survival, although not statistically significant (P = .081) (Fig. 5). At the final follow-up, the AX group showed a survival of 70% while the FX group showed a survival of 86%.
Figure 5.
TEA 4-year reoperation survival analysis comparing AX and FX cohorts: Kaplan-Meier curve for any reoperation at 4 years, stratified by indication of AX versus FX.
Statistical associations
Bivariate analysis demonstrated that men experienced significantly more complications (76% vs 33%, P < .05). Reoperations were also significantly more frequent in males (43% vs 19%, P < .05). Patients undergoing TEA for arthritis were significantly younger than those treated for fractures (P < .05). Multivariable analysis predicting complications generated an unstable model that did not show meaningful results regarding a preoperative diagnosis of AX or FX, likely due to limited sample size and event frequency. Men did show a ∼6.4 times higher odds of experiencing complications (95% CI: 2−23) even when controlling for diagnosis, age, and BMI (Table S1). The post hoc power analysis demonstrated that there was significant underpowering present because of the small sample size (Table S2).
Discussion
This study evaluated overall complication rates following TEA as the primary outcome, and reoperation and revision rates as the main secondary outcomes between TEA performed for AX and FX. Over the 4-year follow-up period, nearly 42% of TEAs experienced at least one complication and approximately 23% required reoperation. AX group patients were significantly younger and being male was independently associated with higher rates of both complications and reoperations. Although not statistically significant, CR reoperations were more common in FX TEAs, while AX TEAs more frequently underwent CS procedures. FX TEAs were also found to have a better reoperation survival over time, though also not statistically significant.
Although TEA is known to demonstrate higher complication rates than arthroplasty procedures of the hip and knee, the rate found by this study is higher than that of current TEA literature.6,11 This could be partially explained by a limited caseload, with each surgeon performing, on average, 1−2 TEAs per year. While this adds to the generalizability of the study by reflecting the practice of most hand surgeons, it also highlights lower exposure to the difficult TEA procedure. Higher surgical caseload for other orthopedic procedures has been shown to result in better outcomes.12,13 The infrequency of TEA being performed by the surgeons in this study could be tied to the high complication and reoperation rates.
The findings of this study support literature that has shown TEA to be performed predominantly on older individuals and females.2,14, 15, 16 This could be explained by the age-related postmenopausal hormonal changes that females experience, which often manifest as osteoporosis, leading to a higher risk of orthopedic trauma. It has been estimated that in the United States, DXA scan evaluated osteoporosis is present in 20% of females greater than 50 and 30% of females greater than 65.17 Additionally, arthritis also progresses with age, leading to increased pain and disability, thus necessitating surgical intervention such as TEA. The data also demonstrated that patients from the FX group were significantly older. A similar explanation can be proposed that osteoporosis prevalence, and thus fracture rate, increase with age for both sexes, just slower and at a later age for men than for women.18
This study also showed that, although statistically insignificant, there were more elbows that encountered complications and reoperations within the AX group than within the FX group. This could be attributed to the progressive and systemic nature of arthritis, especially rheumatoid arthritis, which is not completely cured with a single joint arthroplasty. Additionally, rheumatoid arthritis patients undergoing arthroplasty may have slower recovery because of often receiving steroids and disease-modifying antirheumatic drugs.19 These differences could also have been affected by the AX group being significantly younger than the FX group and the associated elbow usage. Previous literature on TEA has shown that younger patients tend to put more demand on their implants, likely due to higher physical activity levels and less compliance with postoperative restrictions, thus increasing their complication and reoperation rates.20
Although the AX group had proportionately more elbows that encountered complications and reoperations, the FX group had a higher CR reoperations percentage as well as a shorter time to first reoperation and revision. This could be due to the severe localized damage caused by trauma, as well as the technical difficulty of treating complex elbow fractures.21 These factors could increase the complexity of the TEA procedure and the risk of early, major reoperations.
Interestingly, the Kaplan-Meier survival analysis curves looking at reoperations suggest TEA cases performed for AX have higher event rates than those performed for FX, though nonsignificant. This could be explained by the progressive nature of arthritic conditions that, especially with time, cause significant compounding joint degeneration due to chronic inflammation and wear.22 Thus more issues are expected to surface down the line with TEAs performed for AX, leading to an increased number of necessary reoperations. The number of TEAs experiencing a revision matches what is reported in current literature.2
The data demonstrated that males who underwent TEA experienced significantly more complications and reoperations. Multivariable regression also supported males having a higher odds of having complications. A study by Zhang et al23 similarly demonstrated that being male was associated with higher complication and reoperation rates post-TEA. Literature shows that males tend to participate in more high-demand physical activities after TEA, likely placing a larger burden on the implant and not complying with their postoperative restriction protocols.24 This finding is consistent with trends observed in other arthroplasty literature. Prior studies in total knee and hip arthroplasty have shown that males are at higher risk of surgical site complications and reoperation, which has been attributed to greater body mass, higher physical activity levels, and higher rates of smoking.8, 9, 10 Although this data set did not allow for direct assessment of activity level or smoking history, these factors may help explain the sex-related differences observed in this study. Importantly, given the relatively small sample size and retrospective design, these findings should be interpreted with caution and warrant confirmation in larger prospective cohorts that incorporate standardized measures of activity and compliance.
The main limitation of this study is the small sample size and low event count, confirmed by post hoc power analysis. This reduced statistical power and multivariable model stability, precluded controlling for multiple confounders, and resulted in a decreased detection of statistically significant associations. Thus, these findings should be interpreted as exploratory rather than confirmatory, and larger studies are needed to validate these associations. As a retrospective review from a single academic institution, generalizability to other populations is limited, and the 4-year minimum follow-up may overlook late complications and reoperations. Additionally, surgical approach and implant selection were based on individual surgeon preference and not standardized, introducing heterogeneity and further limiting generalizability. Using revision as a measure of implant failure likely underestimates true rates, as not all symptomatic patients undergo treatment. Finally, we could not robustly assess variables such as hand dominance and patient activity level, which may influence rehabilitation demands, soft-tissue healing, and implant loading. Future multi-institutional registries would provide larger sample sizes, improve statistical power, and enhance external validity. Such collaborative efforts should be a priority for future TEA research.
Despite these limitations, the findings of this study are of value because of the lack of literature comparing outcomes of TEA performed for arthritis and distal humerus fracture.25 This study demonstrates that, despite modern surgical advances, TEA is a procedure that still experiences substantial rates of complications and revisions. It also highlights how the indication for TEA and patient sex influence the postoperative course, but studies with larger sample sizes are needed to confirm statistical significance. Ultimately, this study should aid surgeons in preoperative patient counseling and serve as a foundation for future, larger-scale investigations into high-risk TEA cohorts.
Conflicts of Interest
No benefits in any form have been received or will be received related directly to this article.
Supplementary Data
References
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