SCIENTIFIC ARTICLE

Semiconstrained Total Elbow Arthroplasty for

Posttraumatic Arthritis or Deformities of the Elbow:
A Prospective Study
Izaäk F. Kodde, MD, Roger P. van Riet, MD, PhD, Denise Eygendaal, MD, PhD

Purpose To report the short-term results for posttraumatic total elbow arthroplasty.
Methods We included patients presenting to our hospital with symptomatic chronic posttrau-
matic arthritis or deformities of the elbow, aged 55 to 90 years. All patients had reconstruc-
tion with a Coonrad-Morrey prosthesis. We performed clinical follow-up after 2, 6, 12, 24,
and 36 months, consisting of physical examination, standard radiographs, and calculation of
the Mayo elbow performance index.
Results A total of 17 patients were enrolled in this study and had a mean follow-up of 32
months. Mean preoperative flexion arc was 67° and 105° postoperatively. The mean
preoperative Mayo elbow performance index score was 54 (range, 30 – 80) and improved to
a postoperative score of 93 (range, 60 –100). We encountered 6 complications in 5 patients.
Four complications required surgical intervention and 2 minor complications were treated
noninvasively.
Conclusions Short-term functional outcomes after total elbow arthroplasty in this prospective
cohort of patients with posttraumatic arthritis or deformities of the elbow were good
according to mean postoperative measurements. (J Hand Surg 2013;38A:1377–1382. Copy-
right © 2013 by the American Society for Surgery of the Hand. All rights reserved.)
Level of evidence/type of study Therapeutic IV.
Key words Elbow, functional outcome, posttraumatic, total elbow arthroplasty.

T
HE ELBOW IS INVOLVED IN 7% of all adult frac-
tures, and it is predicted that the number of
fractures of the distal humerus in the elderly
will increase.1,2 The reference standard for the treat-
ment of fractures of the distal humerus is open reduc-
tion and internal fixation (ORIF). Despite advances in
elbow fracture fixation systems, the complication rates
remain high because malunion, nonunion, hardware
From the Department of Orthopaedics, Upper Limb Unit, Amphia Hospital, Breda, The Netherlands;
and the Department of Orthopaedics and Traumatology, Monica Hospital, Deurne, Belgium.
Received for publication January 28, 2012; accepted in revised form March 26, 2013.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Corresponding author: Izaäk F. Kodde, MD, Department of Orthopaedics, Amphia Hospital,
Post-box 90158, 4800 RK Breda, The Netherlands; e-mail: if.kodde@hotmail.com.
0363-5023/13/38A07-0014$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2013.03.051
failure, and/or posttraumatic osteoarthritis are reported
in up to 20% of cases.3,4
The sequelae of these complications and of posttrau-
matic elbow arthritis can be treated by arthrodesis,
interposition arthroplasty, or total elbow arthroplasty
(TEA). Generally, arthrodesis of the elbow relieves pain
and restores strength, but it is accompanied by a major
functional impairment. Interposition arthroplasty re-
lieves pain as well and improves motion, but results are
unpredictable. Persistent instability is often found,
which results in poor functional outcomes.5–7 Good
results of TEA for a broad variety of chronic posttrau-
matic elbow disorders are reported in numerous retro-
spective studies.8 –17
However, most reports on TEA for posttraumatic
conditions originate from authors who were involved in
the design of the implant, and a systematic review by

©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1377

1378 TEA IN POSTTRAUMATIC ELBOW ARTHRITIS
Voloshin et al18 revealed complications in 38% of
TEAs placed for posttraumatic sequelae. These high
complication rates and concerns about the implant du-
rability in this population have limited the widespread
use of TEA for posttraumatic disorders.
The purpose of this study was to prospectively eval-
uate the complication rate and effect of complications
on the early functional outcome of the Coonrad-Morrey
(CM) TEA (Zimmer, Warsaw, IN) for chronic posttrau-
matic elbow arthritis.
PATIENTS AND METHODS
We designed a prospective cohort study to evaluate
clinical results of the CM TEA for symptomatic post-
traumatic arthritis or deformities. Chronic conditions
such as nonunion, malunion, persistent dislocation,
and/or painful arthritis of the elbow were included. We
treated 17 consecutive patients (ages 55– 82 y; 4 men
and 13 women) between 2006 and 2011. Patients with
nontraumatic degenerative changes, acute elbow
trauma, active infection or history of deep infection,
poor compliance with regard to after-treatment, or up-
per extremity paralysis, and patients with a nonrestor-
able triceps function were excluded from the study. We
obtained informed consent from all patients. Exemption
of institutional review board approval was granted, be-
cause the protocol used in this study is the current
standard of care in our hospital.
All patients underwent a preoperative clinical assess-
ment by the surgeon, consisting of range of motion
(ROM), assessment of stability, and calculation of the
Mayo elbow performance index (MEPI). The MEPI is
based on 4 items (pain, range of motion, stability, and
elbow function). A total score between 95 and the
maximum 100 points is considered excellent; 80 to 94
is good; 60 to 79 is fair, and less than 60 points is poor.
We obtained standard calibrated radiographs (antero-
posterior and lateral) of the elbow before surgery. A
single surgeon (D.E.) performed all procedures.
Postoperative clinical evaluation by an orthopedic
nurse practitioner took place at 8 weeks, 6 months, and
1, 2, 3, and 4 years, and consisted of range of motion,
strength, stability, neurological status, and standard an-
teroposterior and lateral radiographs. The MEPI ques-
tionnaire was completed. Radiographs were assessed
for periprosthetic fractures, heterotopic ossifications,
bushing wear, and radiolucent lines. We classified het-
erotopic ossification according to Hastings and Gra-
ham.19 Class I lesions are subclinical. Class IIA lesions
limit flexion-extension. Class IIB lesions limit prona-
tion-supination. Class IIC lesions limit motion in both
planes. Class III describes complete ankylosis. Bushing
JHS 䉬 Vol A, July 
wear was recognized as an asymmetric angle of more
than 7° of the CM implant at the bearing surface, as a
result of deterioration of the ulnohumeral polyethylene-
bearing surface.20 Radiolucent lines were classified and
subdivided into 5 types: type 0, no radiolucent lines or
lines involving less than 1 mm and less than 50% of
interface; type 1, lines involving greater than 1 mm and
less than 50% of interface; type 2, lines involving
greater than 1 mm and greater than 50% of interface;
type 3, lines involving greater than 2 mm and complete
interface; and type 4, clear radiographic signs of loos-
ening, such as shifting of the components.13
Surgical technique
We administered prophylactic antibiotics (1,000 mg
cephazolin intravenously) 30 minutes preoperatively.
We made a posterior midline skin incision and used a
triceps-splitting approach. The ulnar nerve was identi-
fied, released, not transposed, and protected throughout
the procedure. We identified the medial and lateral
collateral ligaments when possible and released them at
their humeral attachments. The distal humerus and
proximal ulna were prepared for a CM prosthesis. We
implanted prostheses using tobramycin-impregnated
bone cement (Simplex Bone Cement Powder; Stryker,
Hamilton, Ontario, Canada). Postoperatively, antibiot-
ics were continued for 48 hours, and oral meloxicam
was routinely prescribed for 1 week.
The elbow was placed in 90° flexion with neural
rotation in a plaster splint. After 48 hours, a removable
splint was applied in 30° flexion and physical therapy
was started. During the first 6 weeks, active extension
was avoided. Patients were advised to not lift objects
over 5 kg.
We performed statistical analysis using paired t-test,
sign test, and Wilcoxon signed-ranks test to compare
preoperative and postoperative changes in numerical
data. We used the independent t-test to compare numer-
ical data between groups of patients in this cohort.
Results were considered statistically significant at
P ⬍ .05.
RESULTS
Initial clinical data
A total of 17 patients with a minimum follow-up of 12
months were enrolled in the study. One patient died 4
years after surgery of causes unrelated to the TEA.
There was no further loss to follow-up. The average age
of patients at time of surgery was 70 years (range,
55– 82 y). The dominant elbow was affected in 47% of
patients. Mean time of follow-up was 32 months (range,
 TEA IN POSTTRAUMATIC ELBOW ARTHRITIS 1379

TABLE 1. Comparison of Elbow Function, Heterotopic Ossifications, Complications, and MEPI Score
Between Patients With and Without Previous Operations
Patients Preoperative Postoperative Preoperative Postoperative Heterotopic
(%) FE FE Prosup Prosup Ossification Complications MEPI

Previous 14 (82%) 74° 107° 114° 134° 6 4 93

operation
No previous 3 (18%) 35° 93° 113° 90° 2 1 97
operation

FE, flexion-extension arc; Prosup, prosupination arc.

TABLE 2. Preoperative and Postoperative Range of Motion

Flexion Extension Flexion Arc Pronation Supination Prosupination Arc

Preoperative 100 33 67 57 57 114

Postoperative 126 21 105 66 60 126
P value .001 .112 .002 .076 .579 .215

12– 69 mo), and the average time from injury to surgery
was 100 months (range, 2 mo to 56 y).
There was severe posttraumatic arthritis of the elbow
joint in 11 patients. Four patients had a malunion after
an intra-articular fracture of the distal humerus, 1 had
nonunion after an intra-articular fracture of the distal
humerus, and 1 had nonunion of an extra-articular frac-
ture of the distal humerus. These injuries also resulted
in 2 flail elbows, 1 ankylosis, and 1 ulnar nerve dys-
function. Initial injuries included 1 or more fractures in
16 patients, consisting of humerus fractures in 10 pa-
tients, radius fractures in 6, and ulna fractures in 3. Six
of these had fracture-dislocations. One patient had post-
traumatic arthritis resulting from a chronic posterolat-
eral dislocation.
A total of 14 patients (82%) had previous surgery on
the elbow before implantation of the TEA. Previous
surgery consisted of ORIF in 9 patients, radial head
resection in 2 patients, implantation of a radial head
prosthesis in 2 patients, and a medial epicondyle resec-
tion in 1 patient. Table 1 compares the groups of pa-
tients with and without previous surgery on the elbow.
Functional outcome
The mean preoperative MEPI score was 54 (range,
30 – 80) and improved to a postoperative score of 93
(range, 60 –100) (P ⬍ .001). One patient had a fair
result; the other 16 (94%) had a good or excellent MEPI
score. Table 2 lists preoperative and postoperative mo-
tions.
Radiographic outcome
At the latest follow-up, we found signs of hetero-
topic ossifications in 8 patients (47%), 7 of whom
were classified as Hastings and Graham class I and
1 of whom was classified as class IIA. We saw
radiolucent lines on the radiographs of 4 patients,
1 of whom was graded as type 1 and 3 of whom
were type 4. One patient had a loose humeral
component after a deep infection, 1 had a loose
humeral component after a fall on the arm with a
subsequent periprosthetic fracture, and another pa-
tient had aseptic loosening of the ulnar component.
There were no signs of bushing wear in any of
these patients at latest follow-up. Figures 1 and 2
show an example of failed ORIF followed by TEA.
Complications
In 5 patients (29%) there were a total of 6 complica-
tions. These complications consisted of 2 minor com-
plications not requiring reoperation and 4 major com-
plications requiring surgical management. We found
severe stiffness in 1 patient. Arc of motion improved
from 30° to 80° with intensive physiotherapy and use of
a continuous passive motion machine. The other minor
complication was a superficial skin infection that re-
solved within a week using oral antibiotics.
With regard to the major complications, 1 patient
had persisting ulnar nerve dysesthesia, which resolved
after an ulnar nerve decompression. Three patients had
loosening of a prosthetic component, as described in the

JHS 䉬 Vol A, July 

1380 TEA IN POSTTRAUMATIC ELBOW ARTHRITIS

FIGURE 1: Example of unsuccessful ORIF. This patient had ORIF after a fracture of the distal humerus and subsequently a
second operation with autologous bone substitution and new fixation after an olecranon osteotomy because of a nonunion.
A Anteroposterior view. B Lateral view.

FIGURE 2: The same elbow after removal of hardware during a first operation and implantation of a Coonrad-Morrey prosthesis
during a second operation. A Anteroposterior view. B Lateral view.

section on radiographic outcome. The patient with a maintained. The patient with a deep infection developed a
periprosthetic fracture was treated with a plate osteosyn- chronic draining synovio-cutaneous fistula but accepted
thesis of the humerus, while the humeral component was this situation and refused further surgical intervention. The

JHS 䉬 Vol A, July 

 TEA IN POSTTRAUMATIC ELBOW ARTHRITIS 1381

patient with aseptic loosening has been scheduled for a TABLE 3. Comparison of Complications Between
revision of the loose implant. This Study and the Literature, According to the
Final MEPI scores were 83 for the 5 patients with Systematic Review by Voloshin et al18
complications, compared with 98 for patients without
complications (P ⫽ .09). The ROM was 87°, compared This study, no. Literature,
Complication (%) %
with 112° in favor of patients without complications
(P ⫽ .05). Deep infection (and loosening 1 (6) 3
component)

DISCUSSION Superficial infection 1 (6) *

The results of TEA for posttraumatic elbow disorders
have been reported to be good in most retrospective
studies.8 –17 In this prospective study, functional out-
comes after TEA in patients with posttraumatic arthritis
or deformities of the elbow were good according to the
mean postoperative MEPI score (93). One patient
with loosening of the humeral component and a
malunion of the humerus after a traumatic
periprosthetic fracture had a fair result. These re-
sults are slightly better than results reported by
others (64% to 83% of patients with a good or
excellent result and mean MEPI scores of 75– 82
points for posttraumatic prosthesis place-
ment).8,13,15,17,21 However, some of these studies
were based on earlier generations of implants or had
a longer patient follow-up and therefore reported
more implant-related complications.17,20
There were 14 patients (82%) with previous surgery
on the elbow, which is similar to 90% in a series by
Throckmorton et al.17 Prior surgery increases perioper-
ative risks because of possible altered anatomy, loss of
bone stock, heterotopic ossification, wound problems,
and infections. In the current study, there were no
significant differences in motion, MEPI scores, and
complications between patients with and without pre-
vious operations. However, this comparison is under-
powered, because there were only 3 patients without
prior surgery.
The semiconstrained linked design of the CM pros-
thesis is well suited for posttraumatic reconstruction
because its function does not depend on the integrity of
the epicondyles, collateral ligaments, or radial head.
This may account for the relatively good results in our
cohort. However, it has also been suggested that this
design may be at risk for early bushing wear in this
population.22 Cil et al22 observed evident bushing wear
in all 5 study patients who had deficiency of the epi-
condyles and were aged younger than 65 years, within
5 years.22 This phenomenon can be explained by the
fact that the increased constraint offered by a linked
design places greater stress on the bushing and implant–
bone interfaces, which may lead to increased rates of
bushing wear and/or component loosening. Wright et
Aseptic loosening component 1 (6) 14
Periprosthetic fracture (and 1 (6) 2
loosening component)
Ulnar nerve dysesthesia 1 (6) 3
(without nerve
transposition)
Limited range of motion 1 (6) *
Triceps tendon dissection 0 2
(triceps split approach)
Overall 6 (35) 38
*No information in systematic review.
al23 reported on 10 patients who had a CM revision
because of bushing wear or C-ring failure after an
average of 60 months (range, 9 mo to 12 y).23 In the
current study, there were no radiographic signs of bush-
ing wear at follow-up, although 1 case of early aseptic
loosening occurred.
Complication rates after TEA are higher than those
after replacement surgery of other large joints.24 Until
1993, the complication rate after TEA was up to 43%,
decreasing to 22% to 38% in recent literature, according
to a systematic review by Voloshin and colleagues.18
They found a complication rate of 38% for posttrau-
matic TEA, compared with 22% and 24% for TEA in
acute distal humerus fractures and rheumatoid arthritis,
respectively, with a significant difference between the
acute fractures and chronic posttraumatic arthritis. The
most frequent reported complications were aseptic
component loosening (5% based on clinical examina-
tion; 14% based on clinical examination and radio-
graphic radiolucency), instability (5%), and deep infec-
tion (3%). There were significantly fewer reports of
instability in patients who had a linked device18; how-
ever, this may be at the cost of component loosening. In
our series, there were 3 patients with component loos-
ening. A deep infection occurred in 1 patient. These
results are in accord with the numbers of Voloshin et al
(Table 3). The minor complications (limitation of mo-
tion and superficial skin infection) we report are not
described in their systematic review. With inclusion of
these minor complications, our overall complication

JHS 䉬 Vol A, July 

1382 TEA IN POSTTRAUMATIC ELBOW ARTHRITIS
rate of 35% is comparable to other studies. However, if
temporary postoperative stiffness of the elbow were
discarded, the complication rate would be 29%.
This study is limited by the short-term follow-up. In
particular, implant-related complications may be under-
rated because complications tend to occur with time.
Continuation of follow-up is therefore necessary to
evaluate implant-related long-term complications. An-
other limitation is the relatively small number of pa-
tients included in this cohort. Further prospective stud-
ies based on larger groups of patients are needed to
compare posttraumatic subgroups.
Most of the current literature on CM TEA for post-
traumatic elbow trauma is authored by the implant
developers and might therefore be at risk for systematic
bias.25 The current study addresses TEA for posttrau-
matic elbow arthritis in a prospective fashion, in a
European institution, which was independent from the
development of the implant. The functional outcomes
after TEA in this cohort of patients with posttraumatic
arthritis of the elbow were good according to the mean
postoperative MEPI score of 93. Despite the advances
in TEA designs, the complication rate of 35% in the
current study remains high. Although the differences
were not significant, there is a tendency for these com-
plications to adversely affect MEPI scores and motion
in these patients. In general, TEA can still be considered
as the salvage procedure of choice for posttraumatic
elbow disorders.
REFERENCES
1. Bernardino S. Total elbow arthroplasty: history, current concepts,
and future. Clin Rheumatol. 2010;29(11):1217–1221.
2. Palvanen M, Kannus P, Niemi S, Parkkari J. Secular trends in distal
humeral fractures of elderly women: nationwide statistics in Finland
between 1970 and 2007. Bone. 2010;46(5):1355–1358.
3. Hastings H II, Theng CS. Total elbow replacement for distal hu-
merus fractures and traumatic deformity: results and complications
of semiconstrained implants and design rationale for the Discovery
Elbow System. Am J Orthop. 2003;32(9 Suppl):20 –28.
4. Chalidis B, Dimitriou C, Papadopoulos P, Petsatodis G, Giannoudis
PV. Total elbow arthroplasty for the treatment of insufficient distal
humeral fractures: a retrospective clinical study and review of the
literature. Injury. 2009;40(6):582–590.
5. Nolla J, Ring D, Lozano-Calderon S, Jupiter JB. Interposition ar-
throplasty of the elbow with hinged external fixation for post-
traumatic arthritis. J Shoulder Elbow Surg. 2008;17(3):459 – 464.
6. Larson AN, Adams RA, Morrey BF. Revision interposition arthro-
plasty of the elbow. J Bone Joint Surg Br. 2010;92(9):1273–1277.
JHS 䉬 Vol A, July 
7. McAuliffe JA, Burkhalter WE, Ouellette EA, Carneiro RS. Com-
pression plate arthrodesis of the elbow. J Bone Joint Surg Br.
1992;74(2):300 –304.
8. Hildebrand KA, Patterson SD, Regan WD, MacDermid JC, King GJ.
Functional outcome of semiconstrained total elbow arthroplasty.
J Bone Joint Surg Am. 2000;82(10):1379 –1386.
9. Inglis AE, Inglis AE, Jr., Figgie MM, Asnis L. Total elbow arthro-
plasty for flail and unstable elbows. J Shoulder Elbow Surg. 1997;
6(1):29 –36.
10. Lee DH. Post-traumatic elbow arthritis and arthroplasty. Orthop Clin
North Am. 1999;30(1):141–162.
11. Mansat P, Morrey BF. Semiconstrained total elbow arthroplasty for
ankylosed and stiff elbows. J Bone Joint Surg Am. 2000;82(9):1260 –
1268.
12. Moro JK, King GJ. Total elbow arthroplasty in the treatment of
post-traumatic conditions of the elbow. Clin Orthop Relat Res.
2000;(370):102–114.
13. Morrey BF, Adams RA, Bryan RS. Total replacement for post-
traumatic arthritis of the elbow. J Bone Joint Surg Br. 1991;73(4):
607– 612.
14. Ramsey ML, Adams RA, Morrey BF. Instability of the elbow treated
with semiconstrained total elbow arthroplasty. J Bone Joint Surg Am.
1999;81(1):38 – 47.
15. Schneeberger AG, Adams R, Morrey BF. Semiconstrained total
elbow replacement for the treatment of post-traumatic osteoarthrosis.
J Bone Joint Surg Am. 1997;79(8):1211–1222.
16. Schneeberger AG, Meyer DC, Yian EH. Coonrad-Morrey total el-
bow replacement for primary and revision surgery: a 2- to 7.5-year
follow-up study. J Shoulder Elbow Surg. 2007;16(3 Suppl):S47–
S54.
17. Throckmorton T, Zarkadas P, Sanchez-Sotelo J, Morrey B. Failure
patterns after linked semiconstrained total elbow arthroplasty for
post-traumatic arthritis. J Bone Joint Surg Am. 2010;92(6):1432–
1441.
18. Voloshin I, Schippert DW, Kakar S, Kaye EK, Morrey BF. Com-
plications of total elbow replacement: a systematic review. J Shoul-
der Elbow Surg. 2011;20(1):158 –168.
19. Hastings H II, Graham TJ. The classification and treatment of
heterotopic ossification about the elbow and forearm. Hand Clin.
1994;10(3):417– 437.
20. Lee BP, Adams RA, Morrey BF. Polyethylene wear after total elbow
arthroplasty. J Bone Joint Surg Am. 2005;87(5):1080 –1087.
21. Amirfeyz R, Blewitt N. Mid-term outcome of GSB-III total elbow
arthroplasty in patients with rheumatoid arthritis and patients with
post-traumatic arthritis. Arch Orthop Trauma Surg. 2009;129(11):
1505–1510.
22. Cil A, An KN, O’Driscoll SW. Custom triflange outrigger ulnar
component in revision total elbow arthroplasty. J Shoulder Elbow
Surg. 2011;20(2):192–198.
23. Wright TW, Hastings H. Total elbow arthroplasty failure due to
overuse, C-ring failure, and/or bushing wear. J Shoulder Elbow Surg.
2005;14(1):65–72.
24. Gschwend N, Simmen BR, Matejovsky Z. Late complications in
elbow arthroplasty. J Shoulder Elbow Surg. 1996;5(2):86 –96.
25. Labek G, Neumann D, Agreiter M, Schuh R, Böhler N. Impact of
implant developers on published outcome and reproducibility of
cohort-based clinical studies in arthroplasty. J Bone Joint Surg Am.
2011;93(suppl 3):55– 61.