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Arthroplasty
of the Upper
Extremity
A Clinical Guide from
Elbow to Fingers
Graham J. W. King
Marco Rizzo
Editors

123
Arthroplasty of the Upper Extremity
Graham J. W. King • Marco Rizzo
Editors

Arthroplasty of the
Upper Extremity
A Clinical Guide from
Elbow to Fingers
Editors
Graham J. W. King Marco Rizzo
Roth McFarlane Hand & Upper Limb Department of Orthopedic Surgery
Centre Mayo Clinic
St Joseph’s Health Care Rochester, MN
London, ON USA
Canada

ISBN 978-3-030-68879-0    ISBN 978-3-030-68880-6 (eBook)

https://doi.org/10.1007/978-3-030-68880-6

© Springer Nature Switzerland AG 2021

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
I dedicate this book to my loving and supportive parents Ian
and Ethelwynne; my beautiful wife and soul mate Denise; and
my three amazing children Stephanie, Leanna, and Ian who
provided me the opportunity, encouragement, and inspiration
for this and many other projects that I have pursued during my
“spare time.” I am also grateful to my mentors Robert
McMurtry, Cyril Frank, Bernard Morrey, and James Roth for
their wisdom, guidance, and wise council.
Graham J. W. King, MD, MSc, FRCSC
London, Ontario, Canada
I would also dedicate this to my family: my wonderfully
supportive and loving wife and daughter: Hope Marie and
Hope Sol Rim without whom I would be lost. Thank you for
encouraging and allowing me to pursue this work and the many
others throughout my career. I remain indebted to your love,
patience, and kindness. Special thanks also to my parents
Nazario and Maria who’ve sacrificed so that I may have
opportunities. Their love and example remain an inspiration.
Thank you also to the mentors who’ve trained me: William
Hardaker (1942–2015), teacher and mentor extraordinaire,
who saw enough in me to give me a chance in orthopedics;
James Urbaniak, for showing me the value and beauty of
academic medicine; Richard Goldner, for demonstrating how
dedicated, patient centered, and caring a surgeon can be; and
Robert Beckenbaugh (1941–2020) for inspiring, teaching and
nurturing my passion for arthroplasty.
Marco Rizzo, MD
Rochester, Minnesota, United States of America
Preface

Arthritis of the upper extremity often results in significant pain and disability.
Arthroplasty of the arthritic elbow, wrist, and hand relieves pain, preserves
motion, and improves function. While the experience in upper extremity
arthroplasty is less extensive than those of the hip and knee, when successful,
these procedures can be very rewarding for patients. The aim of this book is
to guide practicing upper extremity surgeons, trainees, and therapists on the
contemporary arthroplasty management of arthritis of the elbow, wrist, and
hand.
The genesis of this book dates back to 2018. We were invited by the pro-
gram chairs of The American Society for Surgery of the Hand Annual Meeting
to co-chair a pre-course titled Arthroplasty: Elbow to Fingertips. We divided
each joint into three parts: (1) design considerations, (2) primary arthroplasty,
and (3) revision/failed arthroplasty. We invited national and international
experts to participate and were delighted at their positive responses and
enthusiasm for this endeavor.
The pre-course was a great success and sparked the interest of the repre-
sentatives from Springer to create a book related to this subject matter. Given
the success we experienced with the pre-course, it made sense to have the
book mirror the same outline. Thankfully, most of the meeting presenters
were able to contribute chapters. Countless hours of effort from the authors
have been put into the making of this book. We are greatly indebted to them
and sincerely appreciate their sacrificing time from family and work obliga-
tions to share their expertise and experience.
Having a book dedicated to arthroplasty of the elbow, wrist, and hand is
unprecedented and should prove very useful to upper extremity surgeons. In
addition, the structure of the chapters with sections for each anatomic region
will be efficient for the reader. The design considerations chapters will rein-
force the underlying pathology and provide a greater understanding of the
thought processes related to rationale and development of implants. It is our
hope that this will inspire further creativity and insights to advance the
designs of current implants. The primary arthroplasty chapters will guide sur-
geons on the current indications, technique, and outcomes of primary joint
arthroplasty. The revision/failed chapters should help guide the reader through
the often difficult and challenging options associated with treating patients
who have failed primary arthroplasty.
We sincerely appreciate the invitation from Springer to lead this effort and
for their support throughout these past 2 years. We would like to especially

vii
viii Preface

thank Ms. Abha Krishnan for her steady support and stewardship through this
entire process.
Finally, to our devoted families, who have quietly and lovingly supported
us through this (and many) academic endeavors, we are eternally grateful.
Your love and support inspire us and have made this possible.

London, ON, Canada Graham J. W. King

Rochester, MN, USA Marco Rizzo
Acknowledgments

Arthroplasty of the upper extremity remains considerably less developed than

that of the knee and hip due to the perceived lack of opportunities for manu-
facturers, limiting investment in research and development. Arthritis and dis-
orders of the upper limb are very common and are major causes of disability
and loss of function for daily activities, work, and sports. There have been
significant advances in upper extremity joint arthroplasty in recent years;
however, there continues to be an unmet need for patients who could benefit
from reliable and durable implants. This project began as an idea to highlight
the advances in arthroplasty of the upper limb and to serve as a basis for
future work.
A total of 52 authors volunteered their time to contribute to this book.
Each is an acknowledged expert in their area of subspecialty. We express our
deepest appreciation to all the authors who provided their expertise. We
would also like to thank the editors and the publisher for their support of this
project, particularly during the height of the COVID-19 pandemic. It is our
hope that this book will be useful for those interested in advancing the surgi-
cal treatment of patients requiring upper limb joint arthroplasty.

Graham J. W. King and Marco Rizzo

ix
Contents

Part I Total Elbow Arthroplasty

1 Total Elbow Arthroplasty: Design Considerations ����������������������   3

Sebastian A. Müller, Graham J. W. King, and James A.
Johnson
2 Primary Elbow Arthroplasty���������������������������������������������������������� 21
William R. Aibinder and Kenneth J. Faber
3 Non-septic Revision Total Elbow Arthroplasty ���������������������������� 37
Mark E. Morrey and Bernard F. Morrey

Part II Radial Head Arthroplasty

4 Design Considerations in Radial Head Arthroplasty ������������������ 57

Shawn W. O’Driscoll
5 Primary Radial Head Arthroplasty������������������������������������������������ 79
Douglas W. Bartels, Julie Adams, and Scott P. Steinmann
6 Revision/Failed Radial Head Arthroplasty������������������������������������ 95
Emilie J. Amaro, Eric S. Dilbone, James P. Hovis, and
Donald H. Lee

Part III Total Wrist Arthroplasty

7 Design Considerations for Total Wrist Arthroplasty�������������������� 111

Susanne M. Roberts, Joseph J. Crisco III, and
Scott W. Wolfe
8 Primary Total Wrist Arthroplasty�������������������������������������������������� 127
Sandra Pfanner, Giovanni Munz, and
Massimo Ceruso
9 Revision/Failed Total Wrist Arthroplasty�������������������������������������� 145
Michel E. H. Boeckstyns

xi
xii Contents

Part IV Distal Radioulnar Joint Arthroplasty

10 Design Considerations for Distal Radioulnar

Joint Arthroplasty���������������������������������������������������������������������������� 157
Amit Gupta and Luis R. Scheker
11 Primary Distal Radioulnar Joint Arthroplasty ���������������������������� 169
Logan W. Carr and Brian Adams
12 Revision/Failed Distal Radioulnar Joint Arthroplasty ���������������� 181
Chelsea Boe, Abhiram R. Bhashyam, and Doug Hanel

Part V Carpometacarpophalangeal Joint Arthroplasty

13 Design Considerations for Carpometacarpophalangeal
Joint Arthroplasty���������������������������������������������������������������������������� 199
Amy L. Ladd, Avi D. Goodman, and Arnold-Peter C. Weiss
14 Primary Carpometacarpophalangeal Joint Arthroplasty������������ 215
Anton Borgers, Matthias Vanhees, and Frederik Verstreken
15 Revision/Failed Carpometacarpophalangeal
Joint Arthroplasty���������������������������������������������������������������������������� 235
Maria Yan, Nicole Zelenski, Samyd S. Bustos,
Doga Kuruoglu, and Steven L. Moran

Part VI Metacarpophalangeal Joint Arthroplasty

16 Design Considerations for Metacarpophalangeal
Joint Arthroplasty���������������������������������������������������������������������������� 255
Robert D. Beckenbaugh, William F. Ogilvie, and
Jerome Klawitter
17 Primary MCP Arthroplasty������������������������������������������������������������ 285
Marco Rizzo and Peter M. Murray
18 Revision/Failed Metacarpophalangeal
Joint Arthroplasty���������������������������������������������������������������������������� 303
Mohammed S. Hussain, Phillip R. Ross, and Peter J. Stern

Part VII Proximal Interphalangeal Joint Arthroplasty

19 Design Considerations for Proximal Interphalangeal
Joint Arthroplasty���������������������������������������������������������������������������� 315
Yoshitaka Minamikawa
20 Primary Proximal Interphalangeal Joint Arthroplasty���������������� 335
Ian A. Trail
21 Revision/Failed Proximal Interphalangeal
Joint Arthroplasty���������������������������������������������������������������������������� 353
Daniel B. Herren and Stephan F. Schindele
Index���������������������������������������������������������������������������������������������������������� 367
Contributors

Brian Adams, MD Department of Orthopedic Surgery, Baylor College of

Medicine, Houston, TX, USA
Julie Adams, MD Department of Orthopaedic Surgery, University of
Tennessee College of Medicine – Chattanooga, Erlanger Orthopaedic
Institute, Chattanooga, TN, USA
William R. Aibinder, MD Shoulder & Elbow Surgery, SUNY Downstate
Health Sciences University, Brooklyn, NY, USA
Emilie J. Amaro, MD Vanderbilt University Department of Orthopedics,
Division of Hand Surgery, Nashville, TN, USA
Douglas W. Bartels, MD Department of Orthopedic Surgery, Mayo Clinic,
Rochester, MN, USA
Robert D. Beckenbaugh, MD Department of Orthopedic Surgery, Mayo
Clinic, Rochester, MN, USA
Abhiram R. Bhashyam, MD PhD Department of Orthopaedics and Sports
Medicine, University of Washington, Seattle, WA, USA
Chelsea Boe, MD Department of Orthopaedics and Sports Medicine,
University of Washington, Seattle, WA, USA
Michel E. H. Boeckstyns, MD Capio Private Hospital, Section for Hand
Surgery, Hellerup, Denmark
Herlev-Gentofte University Hospital, Section for Hand Surgery, Hellerup,
Denmark
Anton Borgers, MD Orthopedic Department, AZ Monica Hospital,
Antwerp, Belgium
Orthopedic Department, AZ Turnhout Hospital, Turnhout, Belgium
Samyd S. Bustos, MD Division of Plastic and Reconstructive Surgery,
Mayo Clinic, Rochester, MN, USA
Logan W. Carr, MD Department of Orthopedic Surgery, Baylor College of
Medicine, Houston, TX, USA

xiii
xiv Contributors

Joseph J. Crisco III, PhD Bioengineering Laboratory, Department of

Orthopaedics, The Warren Alpert Medical School of Brown University and
Rhode Island Hospital, Providence, RI, USA
Eric S. Dilbone, MD Vanderbilt University Department of Orthopedics,
Division of Hand Surgery, Nashville, TN, USA
Kenneth J. Faber, MD MHPE FRCSC Roth | McFarlane Hand and Upper
Limb Centre, Western University, London, ON, Canada
Giovanni Munz, MD Hand Surgery and Reconstructive Microsurgery Unit,
Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
Avi D. Goodman, MD Department of Orthopaedics, Rhode Island Hospital/
Brown University, Providence, RI, USA
Alpert Medical School of Brown University, Providence, RI, USA
Amit Gupta, MD Department of Orthopedic Surgery, University of
Louisville, Louisville, KY, USA
Doug Hanel, MD Department of Orthopaedics and Sports Medicine,
University of Washington, Seattle, WA, USA
Daniel B. Herren, MD, MHA Department of Hand Surgery, Schulthess
Klinik, Zurich, Switzerland
James P. Hovis, MD Arizona Center for Hand Surgery, Phoenix, AZ, USA
Mohammed S. Hussain, MD University of Cincinnati, Department of
Orthopaedic Surgery, Cincinnati, OH, USA
James A. Johnson, PhD, PEng Roth | McFarlane Hand & Upper Limb
Centre, London, ON, Canada
St. Joseph’s Health Care London, London, ON, Canada
Division of Orthopaedic Surgery, Western University, Schulich School of
Medicine & Dentistry, London, ON, Canada
Mechanical and Materials Engineering, Department of Surgery, Western
University, Faculty of Engineering, Schulich School of Medicine & Dentistry,
London, ON, Canada
Graham J. W. King, MD, MSc, FRCSC Roth | McFarlane Hand & Upper
Limb Centre, London, ON, Canada
St. Joseph’s Health Care London, London, ON, Canada
Division of Orthopaedic Surgery, Western University, Schulich School of
Medicine & Dentistry, London, ON, Canada
Jerome Klawitter, PhD Smith & Nephew, Austin, TX, USA
Doga Kuruoglu, MD Division of Plastic and Reconstructive Surgery, Mayo
Clinic, Rochester, MN, USA
Contributors xv

Amy L. Ladd, MD Chase Hand and Upper Limb Center, Department of

Orthopaedic Surgery, Palo Alto, CA, USA
Donald H. Lee, MD Vanderbilt University Department of Orthopedics,
Division of Hand Surgery, Nashville, TN, USA
Massimo Ceruso, MD Hand Surgery and Reconstructive Microsurgery
Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
Yoshitaka Minamikawa, MD Minamikawa Orthopaedic Surgery/Numba
Hand Center, Naniwaku, Osaka, Japan
Steven L. Moran, MD Division of Plastic and Reconstructive Surgery,
Mayo Clinic, Rochester, MN, USA
Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
Bernard F. Morrey, MD Department of Orthopaedic Surgery, Mayo Clinic,
Rochester, MN, USA
University of Texas Health Science Center, San Antonio, TX, USA
Mark E. Morrey, MD Department of Orthopaedic Surgery, Mayo Clinic,
Rochester, MN, USA
Sebastian A. Müller, MD, PD, FMH Shoulder and Elbow Surgery, Division
of Orthopaedic Surgery and Traumatology, University of Basel, Basel,
Switzerland
Peter M. Murray, MD Department of Orthopedic Surgery, Mayo Clinic,
Jacksonville, FL, USA
Shawn W. O’Driscoll, MD, PhD Department of Orthopedic Surgery, Mayo
Clinic and Mayo Foundation, Rochester, MN, USA
William F. Ogilvie, BS Ensemble Orthopedics, LLC, Austin, TX, USA
Marco Rizzo, MD Department of Orthopedic Surgery, Division of Hand
Surgery, Mayo Clinic, Rochester, MN, USA
Susanne M. Roberts, MD Division of Hand and Upper Extremity Surgery,
Department of Orthopedic Surgery, Columbia University Medical Center,
New York, NY, USA
Phillip R. Ross, MD University of Cincinnati, Department of Orthopaedic
Surgery, Cincinnati, OH, USA
Sandra Pfanner, MD Hand Surgery and Reconstructive Microsurgery Unit,
Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
Luis R. Scheker, MD Kleinert Institute, Louisville, KY, USA
Stephan F. Schindele, MD Department of Hand Surgery, Schulthess Klinik,
Zurich, Switzerland
xvi Contributors

Scott P. Steinmann, MD Department of Orthopaedic Surgery, University of

Tennessee College of Medicine – Chattanooga, Erlanger Orthopaedic
Institute, Chattanooga, TN, USA
Mayo Clinic, Rochester, MN, USA
Peter J. Stern, MD University of Cincinnati, Department of Orthopaedic
Surgery, Cincinnati, OH, USA
Ian A. Trail, MD, FRCS Wrightington Hospital, Wigan, Lancashire, UK
Matthias Vanhees, MD, PhD Orthopedic Department, AZ Monica Hospital,
Antwerp, Belgium
Orthopedic Department, Antwerp University Hospital, Edegem, Belgium
Frederik Verstreken, MD Orthopedic Department, AZ Monica Hospital,
Antwerp, Belgium
Orthopedic Department, Antwerp University Hospital, Edegem, Belgium
Arnold-Peter C. Weiss, MD Department of Orthopaedics, Rhode Island
Hospital/Brown University, Providence, RI, USA
Alpert Medical School of Brown University, Providence, RI, USA
Scott W. Wolfe, MD Hand and Upper Extremity Division, Hospital for
Special Surgery, Department of Orthopedic Surgery, Weill Cornell Medicine,
New York, NY, USA
Maria Yan, MD Division of Plastic and Reconstructive Surgery, Mayo
Clinic, Rochester, MN, USA
Nicole Zelenski, MD Department of Orthopedic Surgery, Mayo Clinic,
Rochester, MN, USA
 Part I
Total Elbow Arthroplasty
 Total Elbow Arthroplasty: Design
Considerations
Sebastian A. Müller, Graham J. W. King,
and James A. Johnson
Introduction
The elbow is a complex tripartite joint, consisting
of the ulnohumeral, the radiocapitellar, and the
proximal radioulnar joints (PRUJ) [1] allowing
for extension and flexion as well as forearm rota-
tion. Compared to the joints of the lower limb,
which are usually weight bearing, loading of the
elbow is relatively low for many activities of
daily living. However, forces transmitted across
the elbow can be high for some activities exceed-
ing three times body weight [2] and thereby chal-
lenging the longevity of total elbow arthroplasty
Dr. King serves as a consultant and receives royalties
from Wright Medical. Neither Dr. Johnson, Dr. Müller,
nor any immediate family member has received anything
of value from or has stock or stock options held in a com-
mercial company or institution related directly or indi-
rectly to the subject of this chapter.
S. A. Müller
Shoulder and Elbow Surgery, Division
of Orthopaedic Surgery and Traumatology, University
of Basel, Basel, Switzerland
G. J. W. King
Roth | McFarlane Hand & Upper Limb Centre,
London, ON, Canada
St. Joseph’s Health Care London,
London, ON, Canada
Division of Orthopaedic Surgery, Western University,
Schulich School of Medicine & Dentistry,
London, ON, Canada
e-mail: gking@uwo.ca
© Springer Nature Switzerland AG 2021
G. J. W. King, M. Rizzo (eds.), Arthroplasty of the Upper Extremity,
https://doi.org/10.1007/978-3-030-68880-6_1
1
(TEA). Several design considerations are neces-
sary to restore the main motion of extension and
flexion in the elbow as well as forearm rotation
while respecting the high loading, which can
occur. The overall goal of TEA is to achieve pain-
less and stable motion for activities of daily liv-
ing, vocations, and avocations [3]. The main
indications for TEA include primary or posttrau-
matic osteoarthritis, rheumatoid arthritis, tumors,
distal humeral fractures and nonunions, and dys-
functional instability. While the incidence of
TEA continues to rise for acute trauma and post-
traumatic sequelae, those for rheumatoid arthritis
have decreased with the advent of more effective
medical management [4–6]. TEA can be either
linked transmitting higher forces along the
implant or unlinked requiring intact ligaments
and good bone stock. Convertible TEAs can be
converted from an unlinked to a linked articula-
J. A. Johnson (*)
Roth | McFarlane Hand & Upper Limb Centre,
London, ON, Canada
St. Joseph’s Health Care London,
London, ON, Canada
Division of Orthopaedic Surgery, Western University,
Schulich School of Medicine & Dentistry,
London, ON, Canada
Mechanical and Materials Engineering, Department
of Surgery, Western University, Faculty
of Engineering, Schulich School of Medicine
& Dentistry, London, ON, Canada
e-mail: jajohnso@uwo.ca
3
4 S. A. Müller et al.
tion if instability is problematic without having to
revise the humeral or ulnar components [7–10].
They can also allow conversion from a distal
humeral hemiarthroplasty to a TEA without
removing the humeral stem.
Hemiarthroplasty of the distal humerus is an
option for selected acute distal humeral fractures
and nonunions, and likely require less weight
restrictions than for TEA. However, the collateral
ligaments must be repairable and a humeral com-
ponent matched in size and shape to the native
ulnar, and radial articulations are essential to
reduce cartilage wear [11–13].
Basic Biomechanics
Kinematics of the Elbow
The primary function of the elbow is to position
the hand in space for bimanual activities. The
principal motions are flexion, extension, prona-
tion, and supination. The flexion-extension
motion has a full range of approximately 0–140
degrees, with an average 30–130 degrees needed
for typical activities of daily living [3, 14, 15].
The flexion-extension axis passes through the
center of curvature of the trochlear groove and
the spherical center of the capitellum [16–20].
This axis varies slightly throughout the flexion-­
extension cycle, and hence the ulnohumeral artic-
ulation has been termed a “sloppy hinge” [16,
19]. This axis is approximately 3–5 degrees inter-
nally rotated from the medial and lateral epicon-
dylar axis, and 4–8 degrees valgus relative to the
humeral long axis [16, 17, 21]. An understanding
of this relatively unique motion has led to the
genesis of “loose hinge” TEA designs.
The carrying angle of the elbow, which differs
from the aforementioned flexion axis, also has
implications with respect to implant design [22].
The carrying angle is measured between the long
axes of the humerus and ulna as measured in the
coronal plane in full extension and supination.
Carrying angles vary considerable among indi-
viduals, and are higher on average in women
(10–15 degrees) than in men (7–12 degrees) [14].
Quite clearly, the establishment of this alignment
is also important with regard to the design of the
ulnohumeral articulation in implants.
Forearm rotation is governed primarily by the
radiocapitellar joint, and proximal and distal
radioulnar joints. The normal range is approxi-
mately 90 degrees of supination to 80 degrees of
pronation, although 50 degrees in either direction
is generally sufficient for most activities of daily
living [3, 15]. The rotation axis runs from the
center of the radial head to close to the fovea of
the distal ulna [23, 24]. Reproducing the native
forearm motion following implant reconstruction
is primarily influenced by the shape and position
of the radial head and capitellar surfaces for the
total elbow replacement systems that replace
both the ulnohumeral and radiohumeral
articulations.
Joint Loading of the Elbow
Muscle loading has a profound impact on articu-
lar biomechanics. The compressive forces gener-
ated across the articulations of the elbow have
been shown to markedly increase joint stability
[25–30]. Biomechanical cadaver-based studies
have clearly demonstrated that active loading
achieved by simulating contraction of the elbow
flexors and extensors results in more consistent
and repeatable flexion-extension motion path-
ways relative to passive control (where the arm is
guided by the investigator) [29].
An understanding of the loads that occur at the
elbow is very relevant with regard to total implant
design and performance. To date, direct measure-
ments using instrumented implants and wireless
telemetry in patients have yet to be developed for
the elbow, and thus an exact measurement of
joint loading is not available. However, it is well
established from a variety of studies that these
magnitudes are far from trivial. The quantifica-
tion of these loads currently relies on computa-
tional approaches. Both simplified
two-dimensional models and more complex
approaches that account for the numerous load-­
bearing structures that cross the joint (i.e., the
articulation, ligaments, capsule, muscles, and
tendons) have been employed [2, 31, 32]. At the
1 Total Elbow Arthroplasty: Design Considerations 5

radiocapitellar joint, up to three times body

weight has been estimated [2]. The resultant
force on the ulnohumeral joint can also approach
three times body weight during weight-training
activities. Push-up exercises can generate forces
approximating 45% of body weight [33]. Also,
the direction of the joint reaction force varies
markedly throughout the flexion-extension cycle,
and this of course has a strong influence on the
axial and bending loads that must be accepted by
the implant and interfaces with bone. With
respect to the relative load distribution between
the ulnar and radial sides, this is very dependent
on the activity and position of the joint (both for
Fig. 1.1 Custom-made linked TEA with anterior and
flexion and forearm rotation). Experimental and posterior humeral flanges as well as a broken ulnar flange
analytical studies have reported variable results, used for management of posttraumatic arthritis. The tip of
with approximately a 60:40 ratio for the radio- the ulnar component has been implanted outside the intra-
medullary canal. A synostosis of the proximal ulna and
capitellar and ulnohumeral sides [31, 34, 35]. In
radius is present. The olecranon is missing indicating poor
light of the foregoing, it is logical to postulate triceps function
that elbow implants are subjected to a wide range
of significant loads that vary markedly in magni-
tude and direction in patients during routine 48]. In general, overconstraint results in higher
activities. loads being transferred through the bone-
implant interface [49], which can lead to
mechanical loosening, while underconstraint
Current Total Elbow Arthroplasty results in elbow instability [50, 51].
(TEA) Principals Unlinked implants transmit less force across
the implant, which should theoretically reduce
The first implantation of a TEA was documented mechanical loosening. In the varus position, an
in 1942 [36], but TEA was not routinely used unlinked TEA with intact ligaments transmits
before the early 1970s. These constrained TEAs approximately half of the loads to the humeral
had a fixed hinge (Fig. 1.1) with reported loos- stem when compared to a linked device [52].
ening rates of 26–68% of one or both stems at This biomechanical advantage of unlinked TEA
the bone-cement interface within 3 years after has yet to be confirmed with a reduction in wear
insertion, which is why this concept was aban- and loosening in clinical studies [10, 30, 48, 53–
doned [37–43]. Semi-constrained linked and 55]. The stability of an unlinked device relies on
unlinked implants were introduced in the 1970s secure ligament repair with strong healing, and
and have continued to evolve over the last good bone stock with no or little bony deformity
50 years [37, 44, 45]. [37, 44, 45, 53, 55–57] (Fig. 1.2). For an unlinked
Improvements in linked implant durability TEA, an intact or replaced radial head is impor-
were achieved with the development of semi-­ tant to improve stability [53, 58–60] (Fig. 1.3). If
constrained implants incorporating a sloppy the aforementioned factors are lacking, a linked
hinge. These implants permit 7–10° of varus-­ TEA is preferred [1, 46, 48, 52, 61–63]. However,
valgus laxity and some internal-external rota- forces on the implant increase for both linked and
tional laxity like that present in the native elbow. unlinked TEAs with insufficient ligaments
With this concept some of the forces are in vitro, stressing the importance of ligament
absorbed by the soft tissues reducing loading to repair where possible for both design concepts
the cement interface and thus loosening [7, 46– [52] (Fig. 1.4).
6 S. A. Müller et al.

a b

Fig. 1.2 (a, b) Joint subluxation in an unstable TEA with a radial head replacement (Sorbie, Wright Medical)

Traditional TEA designs were either linked
or unlinked. In case of revision from an
unlinked to a linked TEA to address instability,
often well-­fixed stems had to be removed,
which means major surgery (Fig. 1.3). Modern
convertible TEA designs can more easily be
converted from unlinked to linked in a short
surgical procedure [8–10]. Moreover, conver-
sion from a hemiarthroplasty to TEA is possi-
ble without removing the humeral stem [8, 9]
(Fig. 1.5).
The 10-year survivorship of linked and
unlinked TEA is 83–90% with better results in
high-volume institutions and in lower-demand
patients [64, 65]. Instability, loosening, and mate-
rial wear continue to be the most common causes
of TEA failure [64–66]. Therefore, design con-
siderations include joint stability in unlinked
TEA, wear reduction in linked TEA, and implant
fixation in linked and unlinked TEA.
Implant Fixation
Implants are usually fixed with acrylic bone
cement into the distal humerus, proximal ulna,
and proximal radius (if needed). Uncemented
implants are not currently commercially avail-
1 Total Elbow Arthroplasty: Design Considerations
a b
Fig. 1.3 (a, b) Fifteen years following an unlinked TEA
for osteoarthritis (Sorbie, Wright Medical), valgus insta-
bility developed due to attenuation of the medial collateral
a b
Fig. 1.4 Convertible implant (Latitude EV, Wright
Medical) with (a) a hole in the humeral spool (red arrow)
for (b) reattachment of the collateral ligaments and the
flexor and extensor muscles, respectively. (c) Additional
stability can be achieved by placing a strong suture
able for TEA but have had some success for
humeral component fixation [45, 67–69]. Secure
fixation of the cement interfaces with implant and
bone is required to accept the significant axial,
bending, and torsional loads that can be gener-
ated at the articulation. The stem should be
inserted carefully into the intramedullary canal to
achieve an optimal cement mantle around the
implant [70]. Modern cementing techniques
7
c d
ligament. (c, d) Revision to a linked implant (Latitude,
Wright Medical). The well-fixed stems were removed and
humeral and ulnar shafts augmented with allograft struts
c
through the spool and a tunnel in the ulna protecting the
reattached ligaments from varus-valgus, distraction, and
rotational forces while healing. (From Wright Medical
Group, N.V., Memphis, TN, USA; with permission)
using cement guns and cement restrictors have
further improved stem fixation [71].
Intramedullary Stem Design
Due to failures of early stemless or short-stem
TEA designs (Fig. 1.6), intramedullary stem fixa-
tion has become standard in TEA [72, 73]. The
8 S. A. Müller et al.

a b d

Fig. 1.5 Convertible TEA (Latitude EV System, Wright radial head, (d) hemiarthroplasty of distal humerus with
Medical). (a) Unlinked TEA with radial head replace- anatomical humeral spool. (From Wright Medical Group,
ment, (b) ulnar cap to link system, (c) linked TEA without N.V., Memphis, TN, USA; with permission)

a b c

Fig. 1.6 (a) Lateral radiograph of a patient with rheumatoid arthritis, (b) postoperative radiograph after a short stem
TEA (Souter-Strathclyde, Stryker), (c) humeral loosening with implant failure at 5 years

optimal stem length is unknown and requires fur-
ther study.
Adding an anterior flange to the humeral com-
ponent permits the insertion of a bone graft on the
anterior humerus, which may enhance the bony
support at a point where the maximum stress has
been found to occur with some implant designs.
The idea is to reduce rotational and posterior-­
directed forces potentially causing loosening [2,
34, 72, 74, 75]. While the anterior flange seems to
reduce the forces for some implants (GSB, Sulzer
Medical [76]; Coonrad-­Morrey, Zimmer [7]), this
may not be the case for other implants. The ante-
rior flange of the Latitude TEA, Wright Medical
did not change the load distribution for axial or
bending moments in an in vitro study [77]. The
authors of this study suggested two possible rea-
sons why an anterior flange may not be needed in
this implant. First, the Latitude humeral compo-
nent has medial and lateral fins on the distal por-
tion increasing the cross-sectional area and thus
the fixation within the cement (Fig. 1.5). Second,
the Latitude implant is made of cobalt chrome,
and as such the forces may not be transmitted to
the distal humerus to the same extent as they are
with less stiff titanium implants.
Finite element and in vitro studies [78, 79]
have shown unequal load distribution with greatly
1 Total Elbow Arthroplasty: Design Considerations
Fig. 1.7 Schematic of a
TEA illustrating anterior
impingement of the
coronoid process on the
anterior flange resulting
in pullout forces being
applied to the ulnar
component. (From
Cheung and O’Driscoll
[80]; with permission)
increased strain adjacent to the implant tip, but
strain reduction relative to the epiphysis of
humerus and ulna. This may lead to stress shield-
ing, bone resorption, and fatigue failure, particu-
larly in the ulna where there is no flange on the
stem. The ideal stem shape, length, and materials
with respect to improving the load distribution of
elbow arthroplasty require further study.
Unlike the loaded joints of the lower limb,
pullout forces, so-called pistoning, may cause
ulnar stem loosening, particularly in linked TEA
(Fig. 1.7). Impingement of the anterior humeral
component flange with a prominent coronoid
process or excessive cement must be avoided.
Moreover, the ulnar stem should not be implanted
too far distally [80]. Anterior flexion impinge-
ment should be reduced in future TEA designs
allowing for high flexion angles regardless of the
presence of an anterior flange.
Smooth stems favor debonding of the implant-­
cement interface and should be avoided in
TEA. In vitro studies showed the highest axial
load resistance was found for stems with rough
9
surface treatment when compared to smooth
stems. Titanium stems showed significantly
higher load resistance compared to cobalt
chrome stems for sintered beads, but similar
results between materials with plasma spray
coatings [81]. Shedding of sintered beads was of
concern in these in vitro studies as well as the
known weakening of the stem substrate in the
course of their application (Fig. 1.8). Titanium
plasma spray surface treatments are likely pre-
ferred for TEA.
In a laboratory setting, the ideal stem cross
section was shown to be rectangular because it
resisted the highest rotational forces when com-
pared to triangular, oval, or round [82] (Fig. 1.9).
Sharp rectangular stems, while providing the
greatest resistance to torsion, should probably be
avoided due to the concern about stress concen-
tration in the cement mantle. To date, in vitro
studies testing surface treatment and cross sec-
tion have used straight stems with a constant
cross section throughout the entire length, which
does not reflect the anatomic situations with
10 S. A. Müller et al.

a b c d

Fig. 1.8 Titanium (left) and cobalt chrome (right) stems stems. Note debonding of the surface treatment in 10 mm
after in vitro testing. (a) 20 mm and (b) 10 mm beaded beaded stems (star; B). (From Hosein et al. [81]; with
stems. (c) 20 mm and (d) 10 mm plasma spray-treated permission)

Fig. 1.9 Resistance to 30

rotational force in this
in vitro study was found
Torque at 5° of Stem Rotation (Nm)

to differ depending on 25
stem cross-sectional
shape. The highest
torque resistance was 20
found for a rectangular
cross section with sharp
15
edges [82]

10

0
Round Sharp
Circular Oval Triangular Rectangular Rectangular

Stem Shape

curved and tapered implants. Nevertheless, Implant Positioning

plasma spray-coated stems with a rectangular
cross section are most likely favorable in vivo as
well. Curved stems are more anatomic however;
their removal is problematic relative to straight-­
tapered stems in the setting of infection. Further
studies are needed to compare the durability of
these two design concepts.
Restoration of the extension and flexion axis is
essential in TEA. Implant malpositioning alters
ligament and capsular tension, muscle moment
arms, and lines of action. This may increase wear
of the articular surfaces and increase stresses in
the implant-bone construct, possibly leading to
 1 Total Elbow Arthroplasty: Design Considerations 11

component loosening or mechanical failure. It has both directions occur even in the hands of subspe-
been shown in an in vitro biomechanical study cialty trained orthopedic surgeons [84] (Fig. 1.11).
that the resultant load is significantly increased if Improved surgical cutting guides or navigation
the humeral component is positioned in anything systems may help to improve accuracy.
but an anatomic location [83] (Fig. 1.10). Among five methods for intraoperative deter-
Correct positioning of the humeral stem relies mination of the extension-flexion axis from the
on the accurate reproduction of the anatomic proximal forearm, the most accurate is to use the
extension-flexion axis, which is determined by ridge of the greater sigmoid notch in combination
the vector through the centers of the capitellum with the center of the radial head [85]. Modern
and the trochlea. However, using visual cues to TEA designs use surgical guides for joint axis
estimate the axis, alignment errors up to 10° in determination and likely improve the accuracy of

4000
Resultant Load (Nmm)

3000

2000

1000

0
Optimal

Anterior

Internal

External

Varus

Varus Internal

Varus External

Valgus

Valgus Internal

Valgus External
Implant Position

Fig. 1.10 Mean bending load in the humeral stem of an Malpositioning of the humeral component resulted in an
instrumented TEA using a cadaver biomechanical model increase in forces in the humeral stem. (From Brownhill
and an in vitro joint motion simulator. The resultant bend- et al. [83]; with permission)
ing load (mean + SD) of the entire flexion range is shown.

a VARUS-VALGUS b INTERNAL-EXTERNAL

9 9
ANTERIOR-POSTERIOR (mm)
INFERIOR-SUPERIOR (mm)

6 6

3 3

0 0

–3 –3

–6 –6

–9 –9
–30 –20 –10 0 10 20 30 40 –30 –20 –10 0 10 20 30 40
MEDIAL-LATERAL (mm) MEDIAL-LATERAL (mm)

Fig. 1.11 (a, b) Error in determination of extension-­ dark gray area represents errors within one standard devi-
flexion axis of the elbow for varus-valgus and internal-­ ation of the mean line and the light gray area the remain-
external rotational alignment, respectively. The solid ing errors. (Adapted from Brownhill et al. [84]; with
black line indicates the mean extension flexion axis. The permission)
12
ulnar component positioning when the radial
head is available.
More anatomic stem designs are required to
improve alignment within the intramedullary
canal as shown for the proximal ulna and distal
humerus [86, 87]. Modular systems or custom-­
designed implants reverse engineered from CT
imaging could be an option in cases of an altered
intramedullary canal due to previous fractures, if
long stems are needed [86], or to better accom-
modate the natural shape of the humerus and
ulna, which varies between individuals [86, 87].
Computer navigation has been clinically used
for spinal surgery as well as knee and hip arthro-
plasty but not for TEA so far. There are some
in vitro studies evaluating navigation approaches
using a laser scanner [88] also in combination
with CT data from the diseased elbow [89] or CT
data from the contralateral distal humerus [90], in
order to define the correct implant position.
Using this technology, commercially available
humeral stems were found to impinge within the
intramedullary canal in some cases causing align-
ment errors in rotation and translation.
Impingement was not observed when shorter
a b
Fig. 1.12 (a, b) Cantilever bending failure of the ulnar stem with periprosthetic fracture of the proximal ulna in a
linked TEA (Coonrad-Morrey, Zimmer). (c, d) Bearing wear, osteolysis, and massive metallosis was noted at surgery
S. A. Müller et al.
(more anatomic) stems were used. It was con-
cluded that humeral stems with a fixed valgus
angulation are difficult to implant correctly and
more variability in varus-valgus stem angulations
is needed to improve the accuracy of implant
positioning [91]. Navigated implant placement
was found to be superior to surgeon placement
using standard mechanical instruments, particu-
larly evident in the setting of distal humeral bone
loss or deformity. Further work is needed to
translate these in vitro findings into improved
TEA designs and implantation techniques.
Implant Wear
Wear of ultrahigh molecular weight polyethylene
(UHMWPE) may induce osteolysis, which favors
implant loosening [92–95]. Implant fatigue frac-
tures may occur at the junction of a well-fixed
and loose stem due to osteolysis (Fig. 1.12) as
well as substrate weakening from the sintering of
beaded surface treatments (Fig. 1.8) [96].
Whereas early TEA designs used metal on
metal bearings, all current linked TEAs feature a
c
1 Total Elbow Arthroplasty: Design Considerations 13

cobalt chrome surface that articulates against an
UHMWPE bearing. Once the UHMWPE bearing
surface is worn completely, the bushings need to
be replaced to avoid metal on metal contact
resulting in metallosis (Fig. 1.12). Some TEA
designs use a “cylindrical” linking mechanism
with a straight cobalt chrome pin [97–99]. Others
use an “hourglass” or “concave cylinder” linkage
designs with greater surface area of contact
(Fig. 1.13). In a computational finite element
analysis [51], the hourglass and concave cylinder
linkages showed a significant decreased edge
loading compared to a traditional cylindrical
linkage design (Fig. 1.14). While edge loading

Design Ulnar Humeral Assembly Cross-section

Cylindrical
(CY)

UHMWPE
bushing CoCr axle

Hourglass
(HG)

UHMWPE CoCr axle

bushing

Concave
Cylinder
(CC)

UHMWPE CoCr axle

bushing

Fig. 1.13 Schematic drawing of three different linkage mechanisms types. (From Willing et al. [51]; with
permission)

Fig. 1.14 Significantly HG–3.69 MPa

higher edge loading
occurred for the CC–3.22 MPa
CY–18.34 MPa
cylindrical linkage
design compared to
hourglass and concave
cylinder shapes. (From
Willing et al. [51]; with
permission)

0 Von Mises stress [MPa] 21

14
was comparable for hourglass and concave cylin-
der designs, the concave cylinder design provided
better varus-valgus stability and thus may be best
suited for TEA with respect to reduction of wear,
osteolysis, and implant failure [96].
 esign Considerations for Distal
D ity restrictions than for TEA [111]. With the
Humeral Hemiarthroplasty
Overview
The first reported hemiarthroplasty of the distal
humerus was implanted in 1925, which was made
of aluminum and bronze with a protective rubber
coating [100]. Other early implants composed of
acrylic, nylon, or Vitallium were reported in case
reports or small case series between 1947 and
1990 [101–105]. A series of ten elbows treated
with a stemless stainless-steel or titanium hemi-
arthroplasty for posttraumatic conditions, rheu-
matoid arthritis, or ankylosis due to hemophilia
was published in 1974. While elbows with post-
traumatic conditions were stable, were painless,
and had a functional range of motion in posttrau-
matic conditions, the results for inflammatory
arthritis or hemophilia were unpredictable or
poor [106].
The main treatment of distal humerus frac-
tures remains ORIF in younger patients with
reconstructable fractures and TEA for older
patients with osteoporosis and unreconstructable
fractures. There has been recent interest in distal
humerus hemiarthroplasty for comminuted
capitellar-­trochlear and supracondylar fractures
in patients too young for a TEA due to the life-­
long activity restrictions required with these
devices and concerns about implant longevity.
The indications for distal humeral hemiarthro-
plasty also include failed ORIF, malunion or non-
union, and avascular necrosis of the capitellum or
the trochlea [13, 107–110]. Some authors do not
recommend distal humeral hemiarthroplasty in
the younger population with distal humeral frac-
tures due to a concern about long-term cartilage
wear. These studies reported the outcome of non-
anatomic distal humeral components where the
contact with the native joint was likely subopti-
S. A. Müller et al.
mal unlike newer anatomically shaped designs
[11, 12].
The advantages of distal humeral hemiarthro-
plasty over TEA are the absence of polyethylene
bearing wear and periarticular osteolysis from
particulate debris. This may lower the risk of
component loosening likely requiring less activ-
introduction of commercially available, anatomi-
cal (Sorbie, Wright Medical; Latitude, Wright
Medical) and nonanatomical (Kudo, Biomet)
implants, outcome studies of hemiarthroplasties
have increased over the last two decades [111].
The convertible Latitude EV system (Fig. 1.5) is
the only available implant with a hemiarthro-
plasty option as most of the aforementioned
implants are no longer marketed. It can be con-
verted to a TEA by adding an ulnar stem and
replacing the anatomical humeral spool with a
differently shaped TEA spool. Hemiarthroplasty
implants are currently not approved for use by
the Food and Drug Administration for the United
States but are available in many other countries.
Design considerations for distal humeral
hemiarthroplasty stems are comparable to
TEA. Stable soft tissue constraint is as important
for a distal humeral hemiarthroplasty, similar to
unlinked TEA. While a lack of polyethylene wear
means osteolysis-mediated aseptic loosening is
unlikely, cartilage degeneration of the proximal
ulna and radial head is an important concern that
requires further study.
Joint Stability
Ligament repair and fixation of fractured epicon-
dyles or condyles are necessary for joint stability,
which can be challenging in the setting of com-
minution. An olecranon osteotomy surgical
approach was commonly employed in early clini-
cal series; it has fallen out of favor [108–110, 112,
113]. While allowing excellent exposure of the
distal humeral articular surface and preservation
of the collateral ligaments, nonunion, prominent
hardware, and conversion to TEA were problem-
atic [111]. Other approaches include triceps-­
splitting [114], triceps-reflecting (Bryan-­Morrey)
1 Total Elbow Arthroplasty: Design Considerations
[115, 116], medial or lateral epicondyle osteot-
omy [117, 118], and subperiosteal lateral collat-
eral ligament release [107]. The authors prefer a
triceps-preserving para-olecranon approach for
acute fractures. It gives appropriate exposure, can
be used for conversion to TEA as well, and does
not require postoperative restrictions for the tri-
ceps repair with greater extension strength [119].
While comminuted parts of the joint surface need
to be removed, fractured condyles and epicon-
dyles with their attached collateral ligaments must
be preserved for repair [111]. Determination of
correct humeral component positioning may be
challenging if both epicondyles are fractured,
which may result in incorrect joint alignment and
altered joint biomechanics. Using the superior
aspect of the olecranon fossa to position the ante-
rior flange and evaluating the tension of the soft
tissues with a triceps-on approach are recom-
mended to estimate the correct depth [111]. The
humeral stem should be internally rotated 14°
relative to the posterior humeral cortex [120].
Epicondyles can be fixed using sutures,
K-wires, or small plates, and torn ligaments can
be repaired with sutures through the hole in the
humeral spool as for TEA (Fig. 1.4) [111]. A
secure repair and healing of epicondyles and col-
lateral ligaments is essential for joint stability,
which is why strengthening should not be started
before 8–12 weeks postoperatively [111]. Once
the epicondyles are radiographically healed and
the elbow is clinically stable, no specific weight
restrictions such as recommended for TEA are
required. However, the patient should be edu-
cated about the need to protect the hemiarthro-
plasty [111].
Cartilage Wear Reduction
Nonanatomic TEA implants that have been used
for hemiarthroplasty (Kudo; Biomet) lead to sub-
stantial cartilage attrition and are no longer on the
market [12]. Degenerative radiographic changes
have also been reported with anatomically shaped
implants, more commonly for the Sorbie than for
the Latitude; however, the clinical results have
been favorable [13, 110].
15
An in vitro study found that the best joint
congruity of the Latitude hemiarthroplasty with
highest contact area was found if the humeral
spool optimally fitted the greater sigmoid notch,
followed by oversized implants. Undersized
implants had the least congruity. Moreover,
congruity was greater for active motion than
passive motion indicating joint reduction due to
muscle loading [121]. Compared to the native
elbow, the mean contact area of an optimally
sized implant decreased 44% for the ulnohu-
meral joint but only 4% for the radiocapitellar
joint [122]. Altered varus and valgus angula-
tions were found for optimally and undersized
implants, whereas the oversized implants best
reproduced native elbow kinematics. Based on
this in vitro data, when choosing between two
implant sizes, the larger one should be selected
[111]. However, regardless of implant size,
alterations in elbow biomechanics were found
with abnormal articular contact, tracking, and
loading and thus may result in cartilage degen-
eration over time [123]. Possible design modifi-
cations of the humeral spool could improve
joint congruity and biomechanics. The stiffer
nature of the metallic implant relative to the
native cartilage of the distal humerus most
likely wears the cartilage of ulna and radial
head over time. Hence, future consideration
should be given to more compliant implant
materials, which should be more cartilage
friendly. Long-term data regarding cartilage
wear and distal humeral hemiarthroplasty dura-
bility is not yet available [111].
Summary
TEA can be either unlinked or linked. Good bone
stock, repaired ligaments, and an intact or
replaced radial head are required for unlinked
TEA. In cases of unstable unlinked TEA, con-
vertible designs have the advantage to be con-
verted to a linked status in a short surgery without
the need of revising well-fixed stems. Wear and
loosening is more often seen in linked TEA.
Improvement of implant designs includes more
anatomic stems with rectangular cross section
16
and surface roughening. Modern concave
cylinder-­
shaped UHMWPE linkage designs
reduce wear and provide good stability. Precise
surgical guidance for correct implant alignment
and fixation is preferable.
Distal humeral hemiarthroplasty for nonre-
constructable distal humeral fractures is a good
option in selected patients with good short- to
mid-term results. Likely less weight restrictions
are required than for TEA. Repair of epicondyles,
condyles, and collateral ligaments is essential.
Joint stability and wear of the ulnar and radial
joint surfaces remain challenging. More ana-
tomic implants using more compliant articular
materials may improve long-term results.
Acknowledgment The authors gratefully acknowledge
Mr. Jakub Szmit for his assistance in the organization and
presentation of this chapter.
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18
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 Primary Elbow Arthroplasty
William R. Aibinder and Kenneth J. Faber
Introduction
Total elbow arthroplasty (TEA) is utilized to treat
various degenerative, inflammatory, and trau-
matic pathologies involving the elbow joint [1–
6]. The surgical goals include creating a painless
and stable joint while maintaining or improving
preoperative range of motion. Early designs
yielded suboptimal clinical and functional out-
comes [7–9]. Improved patient selection, recent
advances in surgical approach and technique, as
well as innovations in implant designs, have
improved outcomes and implant survivorship
[1–3, 10, 11]. Nonetheless, the durability of TEA
remains inferior to the hip, knee, and shoulder.
TEA is limited by a high rate of mechanical fail-
ure and loosening, although infection, triceps
insufficiency, and ulnar neuropathy are also com-
mon [9, 12]. As such, a thorough understanding
of TEA and appropriate patient selection is
imperative to optimize outcomes. TEA should be
reserved for low-demand patients, elderly
patients, and those severely debilitated by elbow
W. R. Aibinder
Shoulder & Elbow Surgery, SUNY Downstate Health
Sciences University, Brooklyn, NY, USA
e-mail: William.Aibinder@downstate.edu
K. J. Faber (*)
Roth | McFarlane Hand and Upper Limb Centre,
Western University, London, ON, Canada
e-mail: kjfaber@uwo.ca
© Springer Nature Switzerland AG 2021
G. J. W. King, M. Rizzo (eds.), Arthroplasty of the Upper Extremity,
https://doi.org/10.1007/978-3-030-68880-6_2
2
pain and/or instability who have failed other non-
surgical and surgical treatment options.
Historical Perspective
In the early twentieth century, several custom
implants were utilized; however, the success of
these implants was limited [13]. Dee reported on
12 patients with rheumatoid arthritis treated
using a linked prosthesis with good early out-
comes [8]. The authors suggested that elbow
arthroplasty should therefore be considered for
other indications aside from rheumatoid arthritis.
As a result, in the 1970s, there was an increasing
interest in TEA design and use; however, high
early complication rates were reported, up to
57% in one series [14–16]. The predominant fail-
ure mechanism was implant loosening that was
attributed to a highly constrained articulation that
transmitted excessive forces to the implant-bone
interface. This led to the development of a
“sloppy” hinge, often described as a semi-­
constrained prosthesis [17, 18].
In an effort to reduce loosening, several inven-
tors developed unlinked prostheses that rely on
the capsuloligamentous structures for stability
[19–23]. Unlinked prostheses allow for their
potential use in younger more active patients.
More recently, convertible designs allow the sur-
geon to make intraoperative decisions on linking
21
22
versus unlinking and have reported good early
results [10, 11, 24–26].
Despite these design modifications, there has
not been a significant increase in the utilization of
TEA worldwide. Additionally, the indications for
TEA have evolved over time. According to a
New York State Department of Health database
study, the number of TEA performed for rheuma-
toid arthritis decreased from 48% to 19% between
1997 and 2006 [6]. During the same time period,
TEA performed for fracture increased from 43%
to 69%. A recent study of the Australian registry
demonstrated a similar trend with a substantial
increase of TEA performed for trauma and a rela-
tively low incidence of TEA performed for rheu-
matoid arthritis [1]. This is likely related to the
development of effective disease-modifying anti-
rheumatic drugs (DMARDs) and biologics used
to treat early inflammatory arthropathy.
Additionally, as indications for TEA expanded in
the 1980s and 1990s, follow-up studies, particu-
larly regarding younger active patients with post-­
traumatic etiology, have demonstrated a persistent
high complication and reoperation rate [27–29].
As our understanding of elbow arthroplasty con-
tinues to evolve and progress, there is continued
support for TEA in elderly low-demand patients
in the treatment of inflammatory arthropathy, dis-
tal humerus fractures, and post-traumatic condi-
tions that have failed other treatment options.
Indications
As outlined above, the predominant indications
for primary TEA include inflammatory arthropa-
thy, acute comminuted unsalvageable distal
humerus fractures in the elderly, post-traumatic
elbow arthritis, tumors, and select cases of pri-
mary osteoarthritis [1–6, 10, 30–34].
Rheumatoid Arthritis
Rheumatoid arthritis commonly affects the
elbow. Larsen et al. described a classification for
radiographic findings in patients with rheumatoid
arthritis [35]. These findings are useful in identi-
W. R. Aibinder and K. J. Faber
fying patients for TEA. Early stages are effec-
tively treated with a combination of medications
and synovectomy. More advanced stages such as
grade 3 where there is loss of articular cartilage
with bony resorption and grade 4 where there are
severe bony destruction and gross instability are
indications for TEA with good functional out-
comes (Fig. 2.1).
Several key factors should be considered when
performing a TEA on a patient with rheumatoid
arthritis or other inflammatory arthropathy. First,
given the systemic nature of the condition, assess-
ment of other joints involved should be consid-
ered. Coordination with colleagues performing
lower extremity arthroplasties and/or shoulder
arthroplasties is imperative to optimize recovery
and the ability to use gait aids. Additionally, an
assessment of the patient’s cervical spine is nec-
essary for consideration of anesthetic
requirements.
Second, a thorough history of the patient’s
current medications is necessary. Given the
increased use of DMARDs and biologics, as well
as steroids, consultation with the patient’s rheu-
matologist is necessary. A discussion should be
had with the patient regarding the increased risk
of infection and wound complication associated
with these medications. Some medications can be
continued throughout the operative and periop-
erative periods, while others need to be sus-
pended for a given period of time [36, 37].
Intraoperative stress-dose steroids are infre-
quently required and may depend on the patient’s
daily dosage.
Distal Humerus Fracture
The expansion of indications for elbow arthro-
plasty to treat distal humerus fractures in the
elderly was the result of poor outcomes and high
complication rates with open reduction and inter-
nal fixation. Distal humerus fractures not ame-
nable to fixation in elderly patients can be
effectively treated with TEA [38–43] (Figs. 2.2
and 2.3). Several studies have demonstrated that
in these cases, TEA leads to a faster return to
function with decreased pain and stiffness
2 Primary Elbow Arthroplasty 23

Fig. 2.1 Pre- and postoperative radiographs of a 60-year-old female 4 years following linked total elbow arthroplasty
for stage 4 rheumatoid arthritis
24 W. R. Aibinder and K. J. Faber

Fig. 2.2 Pre- and postoperative radiographs of a 74-year-­ fixation. An intraoperative conversion to a linked total
old female who had a failed attempt at open reduction and elbow arthroplasty was performed in conjunction with a
internal fixation of a distal humerus fracture. An olecra- tension band repair of the olecranon osteotomy
non osteotomy was used for exposure during the attempted

c­ompared to treating these fractures nonopera- tional outcomes with a lower reoperation rate
tively [44–46]. Elderly females with distal with TEA compared to open reduction and inter-
humerus fractures also tend to have better func- nal fixation [41, 47]. Nonetheless, when treating
2 Primary Elbow Arthroplasty 25

Fig. 2.3 Pre- and 5-year

postoperative radiographs of an
84-year-old female with a distal
humerus fracture treated with total
elbow arthroplasty. The
postoperative course was
complicated by a wound
breakdown that was treated with a
reversed radial forearm flap
26
Fig. 2.4 Radiographs and three-dimensional computed
tomography of a 51-year-old female with a low transcon-
dylar distal humerus fracture treated with an elbow hemi-
distal humerus fractures with TEA, careful evalu-
ation of the proximal extent of the fracture is
imperative to ensure that the humerus can sup-
port a conventional implant.
Elbow hemiarthroplasty is also a described
treatment for nonconstructable distal humerus
fractures (Fig. 2.4). Interest in this procedure
spawned from concerns of premature ulnar com-
ponent loosening in younger patients treated with
total elbow replacements. The procedure involves
replacement of the distal humerus with an ana-
tomic prosthesis that articulates with the native
ulna and radial head. This procedure requires col-
lateral ligaments that are intact or that can be
repaired in a manner that will ensure joint stabil-
ity. A linked implant is required if stable condyles
and competent ligaments that maintain stability
cannot be achieved. Hemiarthroplasty is gener-
ally only indicated in younger patients with low
transcondylar fractures that would be challenging
W. R. Aibinder and K. J. Faber
arthroplasty and open reduction and internal fixation of
the lateral column. Exposure was obtained using an olec-
ranon osteotomy
to restore with stable fixation, particularly in
patients who do not desire the lifelong restric-
tions of a total elbow prosthesis. Distal humeral
hemiarthroplasty is less favorable in the elderly
as it requires healing of the collateral ligaments
leading to prolonged rehabilitation, higher rates
of pain due to ulnar cartilage wear, and higher
reoperation rates [48].
Post-traumatic Arthritis
Following fracture, dislocation, or other injury
about the elbow, there is often a development of
post-traumatic degenerative changes or residual
instability. Unlike inflammatory arthropathy and
distal humerus fractures, TEA for post-traumatic
arthritis of the elbow should not be sought as the
initial treatment option given the comparatively
worse clinical and functional outcomes [30]
2 Primary Elbow Arthroplasty
Fig. 2.5 Radiographs of a 68-year-old female with a dis-
tal humerus fracture treated with open reduction and inter-
nal fixation. One month following surgery, joint culture
(Fig. 2.5). Despite the advances already
described, survivability and durability of TEA in
younger active patients are still uncertain.
Surgeons and patients should exhaust all avail-
able nonoperative and operative treatment options
including pain medication, corticosteroid injec-
tions, open and arthroscopic osteocapsular
arthroplasty, and interposition arthroplasty. TEA
should be reserved for when all these options fail
and when patients have been counseled exten-
sively on their activity restrictions following
surgery.
27
was positive for Staphylococcus epidermidis, and a staged
revision from an articulating spacer to a linked total elbow
arthroplasty was performed
Nonetheless, TEA is a reasonable option for
post-traumatic arthritis with reasonable out-
comes, particularly pain relief, reported in the
literature [29, 40, 49]. There are specific factors
to consider when performing a TEA in patients
with post-traumatic arthritis. First, these patients
tend to have prior skin incisions which need to be
considered. Second, prior instrumentation may
make implantation challenging, and careful pre-
operative planning is necessary. Third, as the
majority of these patients are younger, surgeons
may desire to use an unlinked prosthesis to limit
28
mechanical failure; however, careful scrutiny of
the ligament integrity is imperative pre- and
intraoperatively. Fourth, the status of the ulnar
nerve needs to be carefully evaluated preopera-
tively and addressed carefully, specifically in
relation to medial osteophyte formation altering
the cubital tunnel morphology and periarticular
scarring about the nerve [50, 51].
Tumors
Periarticular tumors involving the elbow have
been treated with total elbow arthroplasty in cer-
tain situations. In a series of 47 patients treated at
the Rizzoli institute, only 4% of patients devel-
oped an infection [32]. Similar findings were
demonstrated by Athwal et al. with no infections
in their series of 20 patients despite a high rate of
radiation and/or chemotherapy in the cohort [34].
Both studies demonstrated a relatively high rate
(25%) of nerve injury. Overall, the use of total
elbow arthroplasty in the treatment of primary
and metastatic tumors is a reasonable modality.
Primary Osteoarthritis
Primary TEA is rarely indicated for primary
osteoarthritis of the elbow [52] (Fig. 2.6).
The condition is commonly seen in the domi-
nant extremity of males who are manual laborers
and in their 40s and 50s [53]. The ulnohumeral
cartilage is often spared in these patients, and the
primary symptoms are pain at the end range of
motion, stiffness, and mechanical symptoms.
These symptoms are often effectively addressed
with an elbow debridement, either open or
arthroscopic. However, some patients have carti-
lage loss and develop pain at the mid-arc range of
motion and may be candidates for TEA. Unlike
patients with inflammatory arthropathy, these
patients tend to have a high baseline level of
function. A thorough preoperative discussion is
necessary to ensure that patients are willing to
abide by the activity restrictions of a primary
TEA in exchange for the potential pain relief.
Providers must discuss with the patients the risk
W. R. Aibinder and K. J. Faber
of mechanical failure and the challenges with
addressing these complications in the revision
setting.
Postoperative Rehabilitation
The postoperative rehabilitation plan should be
structured to minimize the risk of early complica-
tions and to restore elbow function. The initial
postoperative dressing includes significant pro-
tective padding and an anterior splint that avoids
pressure on the surgical site and prevents elbow
motion [54]. Motion exercises are initiated once
satisfactory wound healing is established. The
limits of motion are determined by the motion
attained intraoperatively. Static progressive flex-
ion and extension splinting is occasionally
required for patients that have difficulty regain-
ing functional arcs of motion. Resisted exercises
are permitted once satisfactory motion has been
restored in patients treated with a triceps-“on”
approach. Resisted exercises are withheld for
3 months when a triceps-“off” approach is used.
Triceps-“off” approaches include the
­Bryan-­Morrey triceps-reflecting approach
(Fig. 2.7) [55], the longitudinal triceps-splitting
approach (Fig. 2.8) as described by Gschwend
et al. [56], and triceps turndown approaches [57,
58]. The triceps-“on” approach includes the
paratricipital approach as described by Alonso-
Llames, which is limited by the ability to appro-
priately prepare the ulnar canal [59]. The lateral
para-olecranon approach (Fig. 2.9) allows the
ability to maintain the continuity of the extensor
mechanism to accelerate rehabilitation while
improving visualization and access to the ulnar
canal for preparation [60]. This is the authors’
preferred approach for TEA.
Most authors recommend a lifetime lifting
limitation of 2.5 kg.
Outcomes
Outcomes following primary TEA vary substan-
tially depending on the indication as has been
demonstrated through various published studies.
2 Primary Elbow Arthroplasty 29

Fig. 2.6 Preoperative and 2-year postoperative radiographs of a 60-year-old female with primary osteoarthritis treated
with linked total elbow arthroplasty. (Courtesy Dr. G King)
30
Fig. 2.7 Bryan-Morrey triceps-reflecting approach. A
posterior skin incision is used to expose the triceps. The
ulna nerve is mobilized, and the triceps is elevated from
More recently, this difference has been high-
lighted through several systematic reviews
­demonstrating improved outcomes and decreased
revision rates in primary TEA performed for
inflammatory arthropathies and trauma compared
to post-traumatic and degenerative conditions [1,
30, 31]. The difference in outcomes may be
related directly to the etiology or indirectly to the
lower activity demands of certain patients.
Surgeon volume and experience likely also
impact on outcomes. A report from the Scottish
Joint Registry found that implant longevity was
greater with experienced surgeons performing
more than ten cases per year [3]. Nonetheless, it
is prudent to evaluate the outcomes of primary
TEA by indication.
W. R. Aibinder and K. J. Faber
Ulnar nerve
Triceps elevated
from ulna
the proximal ulna in a medial to lateral direction. The lat-
eral triceps is kept in continuity with the anconeus
Rheumatoid Arthritis
Survivorship at 10 years following primary TEA
is approximately 90% for cases performed for
inflammatory arthropathy [1–5, 61–64]. Viveen
et al. demonstrated that the revision rate for pri-
mary TEA performed for primary osteoarthritis
was twice as high as TEA performed for rheuma-
toid arthritis [1].
In a study of the Finnish registry reviewing
1457 primary TEA performed for rheumatoid
arthritis, the authors found a 10-year survival rate
of 83%. The etiology for revision included asep-
tic loosening as the most common, followed by
dislocation, periprosthetic fracture, infection, and
fracture of the prosthesis [5]. A study from the
2 Primary Elbow Arthroplasty
Ulnar nerve
Triceps split
Fig. 2.8 Gschwend triceps-splitting approach. The ulna
nerve is mobilized, and the triceps is split longitudinally
and reflected from the ulna medially and laterally to
expose the elbow joint
Mayo Clinic evaluating the Coonrad-Morrey
“sloppy” hinge prosthesis at a minimum of
10-year follow-up in 78 elbows demonstrates
only moderate or severe postoperative pain in 2
(2.6%) patients with a mean range of motion
from 28° to 131° [61]. The mean Mayo Elbow
Performance Score (MEPS) improved from 42
preoperatively to 87 at final follow-up.
Several studies have assessed the outcomes of
unlinked TEA in the setting of rheumatoid arthri-
tis with 10-year survivorship ranging between
70% and 93% [65–68]. The primary complica-
tion in most studies is aseptic loosening rather
than instability.
More recently, outcomes regarding the use of a
convertible TEA have been reported in the litera-
ture [10, 26]. In one study with a mean follow-­up
31
of 6 years, the authors linked 55 TEA, while 27
were unlinked [10]. The determination for linking
was based on preoperative and intraoperative
finding of collateral ligament integrity. There was
no difference between the two groups with respect
to complications, survivorship, revision rate, and
reoperation rate. The overall complication rate
was 32%. All instability complications occurred
in the unlinked cohort, while aseptic ulnar com-
ponent loosening occurred in the linked cohort. A
convertible implant allows the treating surgeon to
make an algorithmic intraoperative decision to
optimize a patient’s outcome while decreasing the
postoperative complication risk. Nonetheless,
multiple mid- and long-term studies have demon-
strated successful outcomes of primary TEA in
the setting of rheumatoid arthritis.
Distal Humerus Fractures
In long-term studies, the survivorship of TEA for
distal humerus fractures was between 76% and
90% at 10 years [38, 39]. Interestingly, in the
series from the Mayo Clinic, if excluding patients
with rheumatoid arthritis, the survivorship
increased to 92% [38]. The mean range of motion
was from 24° to 123° and a mean MEPS score
90.5. Still 11% of elbows underwent revision for
infections, and 18% underwent revision for
implant complications. Five other elbows sus-
tained periprosthetic fractures.
In a prospective randomized trial, TEA and
open reduction internal fixation yielded similar
results at 2-year follow-up [47]. The reoperation
rate in the TEA group was 12% compared to 26%
in the ORIF group; however, this did not reach
statistical significance. Furthermore, a recent
study demonstrated no difference in outcome for
TEA performed for acute distal humerus frac-
tures or as a salvage for failed internal fixation
[40]. The indications for TEA in the salvage
group were nonunion, post-traumatic arthritis,
hardware failure, intrinsic stiffness, fibrosis,
instability, and malunion. It is important to note
that the mean age in the salvage group was
60 years, compared to 74 years in the acute TEA
group.
32
Medial window
Lateral
paraolecranon
window
Ulna nerve
Fig. 2.9 The lateral para-olecranon approach. The ulna
nerve is mobilized, and two longitudinal arthrotomies are
used to access the joint. The medial arthrotomy is estab-
lished in the floor of the cubital tunnel and extends proxi-
mally along the medial edge of the triceps. The lateral
Thus, when determining the appropriate treat-
ment option for elderly patients with comminuted
distal humerus fractures, surgeons must be able to
apply all the available data and individualize care
with consideration for bone quality, fracture exten-
sion, patient activity level, life expectancy, and
anticipated complications and need for revision.
Nonetheless, primary TEA for unsalvageable dis-
tal humerus fractures yields reasonable functional
outcomes in carefully selected low-­ demand
patients. Surgeons need to be cognizant of the not
insignificant rate of component revision, infection,
and periprosthetic fracture that occurs with TEA in
the treatment of distal humerus fractures [38, 39,
69]. In some instances, low-demand, medically
unwell patients with distal humerus fractures may
achieve satisfactory outcomes with nonoperative
management as well [45].
W. R. Aibinder and K. J. Faber
Ulnar nerve
arthrotomy involves splitting the lateral one third of the
triceps from the medial two thirds. The lateral triceps is
kept in continuity with the anconeus. The majority of the
triceps tendon insertion is undisturbed on the olecranon
An alternative in younger patients with an
unsalvageable distal humerus fracture is a distal
humerus hemiarthroplasty [70–74]. Several
studies have demonstrated reasonable functional
outcomes with hemiarthroplasty. In one study of
26 elbows, Smith et al. demonstrated a mean
MEPS score of 90 but demonstrated a worse
functional outcome in patients who had wear of
the proximal ulna [71]. This is a common find-
ing, occurring in up to 50% of the elbows studied
[71, 73, 74]. Nestorson et al. demonstrated good
outcomes in 42 patients at a mean of 34 months
[72]. Five patients had wear of the olecranon
with a mean MEPS of 90 and DASH of 20. No
studies have demonstrated a high rate of instabil-
ity; rather ulnar wear is the most common com-
plication; however, in most patients it is
asymptomatic.
2 Primary Elbow Arthroplasty
Post-traumatic Arthritis
In one study, implant survivorship at 15 years
was 70% with increased failure associated with
younger age at index arthroplasty [28]. Only
74% of patients were subjectively satisfied.
Bushing wear was attributed as the main cause
of intermediate-­term failure. An earlier study
demonstrated a 27% complication rate despite
good functional outcome and resolution of pain
[49]. These studies demonstrate that patients
who are anticipating heavy use of their elbow
need to be cautioned as to the expected out-
comes with TEA for the treatment of post-trau-
matic arthritis.
A more recent study reviewed 14 patients at a
mean follow-up of 46 months demonstrating
good clinical and functional outcomes with only
3 experiencing complications [75]. Two of these
had worsened ulnar neuropathy, and a third was
complicated by a wound infection and peripros-
thetic humeral shaft fracture. Although a small
and short follow-up series, the outcomes are
more promising.
Still, patients need to be extensively coun-
seled on the high rate of complications and
activity limitations prior to proceeding with pri-
mary TEA.
Additionally, some authors have suggested
that distal humeral hemiarthroplasty is an alter-
native to TEA for patients with post-traumatic
arthritis [70]. Werthel et al. reported on 16
patients with a mean age of 45 years at a mean
follow-up of 51 months [70]. The mean MEPS
score was 72 with 1 poor and 5 fair outcomes.
Fifty percent of patients experienced a complica-
tion and 31% required a revision, 2 of which
were revised to a TEA. Further studies are
required to demonstrate the efficacy and safety of
this alternative option.
Primary Osteoarthritis
Primary TEA for primary osteoarthritis is rarely
performed or indicated. There are a few small
series reported [52, 76, 77]. In one series, 20
elbows were treated for primary osteoarthritis
33
over the course of 27 years, and followed for a
mean of 9 years [52]. The authors noted reason-
able outcomes, with a nearly 50% complication
rate. However, only three elbows required a
return to the operating room with only three
experiencing mechanical failure. Espag et al.
reported the outcomes of an unlinked TEA for
the treatment of primary osteoarthritis with only
one revision despite five components having
radiographic loosening [77]. It is important to
note that the majority of patients in these studies
were over the age of 65 years, and thus TEA was
reserved for older patients.
Conclusion
As we advance into the twenty-first century, the
indications for primary TEA are transitioning
from rheumatoid arthritis to the treatment of
acute trauma and post-traumatic conditions. The
outcomes in inflammatory arthropathy and acute
trauma continue to generally be favorable, par-
ticularly in older low-demand patients. The indi-
cations for TEA, particularly in the post-traumatic
setting, are continuing to increase, and it is antici-
pated that the use of TEA in younger patients will
result in higher complication rates and the need
for reoperation. Advancements in technology,
with novel convertible prosthetic designs and
improved stem fixation may provide better out-
comes in younger patients as the evidence in the
literature continues to grow, specifically in chal-
lenging conditions including dysfunctional insta-
bility and periarticular tumors.
References
1. Viveen J, van den Bekerom MPJ, Doornberg JN,
Hatton A, Page R, Koenraadt KLM, et al. Use and
outcome of 1,220 primary total elbow arthroplasties
from the Australian Orthopaedic Association National
Joint Arthroplasty Replacement Registry 2008-2018.
Acta Orthop. 2019;90(6):511–6.
2. Krukhaug Y, Hallan G, Dybvik E, Lie SA, Furnes
ON. A survivorship study of 838 total elbow replace-
ments: a report from the Norwegian Arthroplasty
Register 1994-2016. J Shoulder Elb Surg.
2018;27(2):260–9.
Another random document with
no related content on Scribd:
apotheosis of womanhood, sketched by Guido Guinizelli, is
developed with mystical fullness, and there is even perhaps a hint of
some future work in honour of Beatrice that will deal with the world
beyond the grave. The two sonnets that follow are a kind of
supplement; the first:

Amore e ’l cor gentil sono una cosa,

“Love and the gentle heart are one same thing,” gives a definition of
love, elaborating the Guinizellian doctrine; the second:

Ne li occhi porta la mia donna Amore,

“Within her eyes my lady carries Love,” pursues the conception

further, to represent Beatrice herself as the creatrix of the divine gift
of gentilezza by which the heart is capable of noble love. Two
sonnets on the death of Beatrice’s father lead up to a veritable lyrical
masterpiece, the canzone:

Donna pietosa e di novella etate,

“A lady pitiful and of tender age,” the anticipatory vision of Beatrice’s

death—the “Dante’s Dream” of Rossetti’s famous picture. The
following sonnet, in which Beatrice and Cavalcanti’s lady, Primavera
or Giovanna, appear together, is the only place in the Vita Nuova
where Dante calls her whom he loved by the name by which she
was actually known—“Bice.” Love now no longer appears weeping,
but speaks joyfully in the poet’s heart. All that was personal in
Dante’s worship seems to have passed away with his earlier
lamentations; his love has become a transcendental rapture, an
ecstasy of self-annihilation. This part of the book culminates in the
two sonnets:
 Tanto gentile e tanto onesta pare,

“So noble and so pure seems my lady,” in which a similar sonnet of

Guinizelli’s is easily surpassed, and

Vede perfettamente onne salute,

“He seeth perfectly all bliss, who beholds my lady among the ladies”;
sonnets which are flawless gems of mediaeval poetry. Then abruptly,
in the composition of a canzone which should have shown how Love
by means of Beatrice regenerated his soul, the pen falls from his
hand: Beatrice has been called by God to Himself, to be glorious
under the banner of Mary, “How doth the city sit solitary that was full
of people!”
Some falling off may be detected here and there in the third part of
the Vita Nuova (xxix. to xli.), which includes the prose and poetry
connected with Beatrice’s death, the love for the lady who takes pity
upon the poet’s grief, his repentance and return to Beatrice’s
memory. A stately canzone:

Li occhi dolenti per pietà del core,

“The eyes that grieve for pity of the heart,” is a companion piece to
the opening canzone of the second part; the poet now speaks of
Beatrice’s death in the same form and to the same love-illumined
ladies to whom he had formerly sung her praises. More beautiful are
the closing lines of the shorter canzone, written for Dante’s second
friend, who was apparently Beatrice’s brother. After the charming
episode of the poet drawing an Angel on her anniversary, the “gentle
lady, young and very fair,” inspires him with four sonnets; and his
incipient love for her is dispelled by a “strong imagination,” a vision of
Beatrice as he had first seen her in her crimson raiment of childhood.
The bitterness of Dante’s repentance is a foretaste of the confession
upon Lethe’s bank in the Purgatorio. The pilgrims pass through the
city on their way to Rome, “in that season when many folk go to see
that blessed likeness which Jesus Christ left us as exemplar of His
most beauteous face, which my lady sees in glory” (V. N. xli.); and
this third part closes with the sonnet in which Dante calls upon the
pilgrims to tarry a little, till they have heard how the city lies desolate
for the loss of Beatrice.
In the epilogue (xlii., xliii.), in answer to the request of two of those
noble ladies who throng the ways of Dante’s mystical city of youth
and love as God’s Angels guard the terraces of the Mount of
Purgation, Dante writes the last sonnet of the book; wherein a “new
intelligence,” born of Love, guides the pilgrim spirit beyond the
spheres into the Empyrean to behold the blessedness of Beatrice. It
is an anticipation of the spiritual ascent of the Divina Commedia,
which is confirmed in the famous passage which closes the “new life”
of Love:
“After this sonnet there appeared unto me a wonderful vision:
wherein I saw things which made me purpose to say no more of this
blessed one, until such time as I could discourse more worthily
concerning her. And to attain to that I labour all I can, even as she
knoweth verily. Wherefore if it shall be His pleasure, through whom is
the life of all things, that my life continue for some years, I hope that I
shall yet utter concerning her what hath never been said of any
woman. And then may it seem good unto Him, who is the Lord of
courtesy, that my soul may go hence to behold the glory of its lady:
to wit, of that blessed Beatrice who gazeth gloriously upon the
countenance of Him who is blessed throughout all ages.”[10]
From the mention of the pilgrimage, and this wonderful vision, it
has been sometimes supposed that the closing chapters of the Vita
Nuova were written in 1300. It seems, however, almost certain that
there is no reference whatever to the year of Jubilee in the first case.
When Dante’s positive statement in the Convivio, that he wrote the
Vita Nuova at the entrance of manhood (gioventute being the twenty
years from twenty-five to forty-five, Conv. iv. 24), is compared with
the internal evidence of the book itself, the most probable date for its
completion would be between 1291 and 1293. It should, however, be
borne in mind that, while there is documentary evidence that some of
the single poems were in circulation before 1300, none of the extant
manuscripts of the whole work can be assigned to a date much
earlier than the middle of the fourteenth century. It is, therefore, not
inconceivable that the reference to the vision may be associated with
the spiritual experience of 1300 and slightly later than the rest of the
book.[11]
The form of the Vita Nuova, the setting of the lyrics in a prose
narrative and commentary, is one that Dante may well have invented
for himself. If he had models before his eyes, they were probably, on
the one hand, the razos or prose explanations which accompanied
the poems of the troubadours, and, on the other, the commentaries
of St. Thomas Aquinas on the works of Aristotle, which Dante
imitates in his divisions and analyses of the various poems. His
quotations show that he had already studied astronomy, and made
some rudimentary acquaintance with Aristotle and with the four chief
Latin poets; the section in which he speaks of the latter, touching
upon the relations between classical and vernacular poetry (xxv.),
suggests the germ of the De Vulgari Eloquentia. The close of the
book implies that he regarded lack of scientific and literary
equipment as keeping him from the immediate fulfilment of the
greater work that he had even then conceived for the glory of
Beatrice.
In the Convivio, where all else is allegorical, Beatrice is still simply
his first love, lo primo amore (ii. 16). Even when allegorically
interpreting the canzone which describes how another lady took her
place in his heart, after her death, as referring to Philosophy, there is
no hint of any allegory about quella viva Beatrice beata, “that
blessed Beatrice, who lives in heaven with the Angels and on earth
with my soul” (Conv. ii. 2). When about to plunge more deeply into
allegorical explanations, he ends what he has to say concerning her
by a digression upon the immortality of the soul (Conv. ii. 9): “I so
believe, so affirm, and so am certain that I shall pass after this to
another better life, there where that glorious lady lives, of whom my
soul was enamoured.”
 Those critics who question the reality of the story of the Vita
Nuova, or find it difficult to accept without an allegorical or idealistic
interpretation, are best answered in Dante’s own words: Questo
dubbio è impossibile a solvere a chi non fosse in simile grado fedele
d’Amore; e a coloro che vi sono è manifesto ciò che solverebbe le
dubitose parole; “This difficulty is impossible to solve for anyone who
is not in similar grade faithful unto Love; and to those who are so,
that is manifest which would solve the dubious words” (V. N. xiv.).

2. The “Rime”
The Rime—for which the more modern title, Canzoniere, has
sometimes been substituted—comprise all Dante’s lyrical poems,
together with others that are more doubtfully attributed to him. In the
Vita Nuova were inserted three canzoni, two shorter poems in the
canzone mould, one ballata, twenty-five sonnets (including two
double sonnets). The “testo critico” of the Rime, edited by Michele
Barbi for the sexcentenary Dante, in addition to these accepts as
authentic sixteen canzoni (the sestina is merely a special form of
canzone), five ballate, thirty-four sonnets, and two stanzas. Dante
himself regards the canzone as the noblest form of poetry (V. E. ii.
3), and he expounded three of his canzoni in the Convivio. From the
middle of the fourteenth century onwards, a large number of MSS.
give these three and twelve others (fifteen in all) as a connected
whole in a certain definite order, frequently with a special rubric in
Latin or Italian prefixed to each; this order and these rubrics are due
to Boccaccio.[12] It has been more difficult to distinguish between the
certainly genuine and the doubtful pieces among the ballate and
sonnets, and the authenticity of some of those now included by Barbi
in the canon is still more or less open to question. The Rime, on the
whole, are the most unequal of Dante’s works; a few of the sonnets,
particularly some of the earlier ones and those in answer to other
poets, have but slight poetic merit, while several of the later canzoni
rank among the world’s noblest lyrics. In the sexcentenary edition
the arrangement of the lyrics is tentatively chronological, with
subsidiary groupings according to subject-matter. While following the
same general scheme, I slightly modify the arrangement, as certain
poems regarded by Barbi as “rime d’amore” appear to me to be
more probably allegorical.
(a) A first group belongs to the epoch of the Vita Nuova.
Conspicuous among them are two canzoni. One:

La dispietata mente che pur mira,

“Pitiless memory that still gazes back at the time gone by,” is
addressed directly to a woman (in this respect differing from Dante’s
other canzoni), who is probably the second lady represented as the
poet’s screen. The other:

E ’m’ incresce di me si duramente,

“I grieve for myself so bitterly,” seems to give fuller expression to the

first part of the Vita Nuova with an alien note—the image of the little
maiden has yielded to that of the woman whose great beauty is the
object of unattainable desire. At times a lighter note is struck; Dante
is apparently simply supplying words for composers to set to music,
or revealing a spirit of playfulness of which there is no trace in the
Vita Nuova.[13] Besides sonnets in honour of Beatrice, we have a
few relating to other women, and in two ballate even their names are
given: Fioretta and Violetta. One delightful sonnet:

Sonar bracchetti e cacciatori aizzare,

“Beagles questing and huntsmen urging on,” reveals the poet taking
part in sport and appreciating a jape at his own expense. A number
of correspondence sonnets belong to this epoch, a small series
addressed to Dante da Maiano (of which no MS. has been
preserved) being probably earlier than the first sonnet of the Vita
Nuova. A note of pure romance is struck in the charming sonnet to
Guido Cavalcanti, in which the younger poet wishes that they two,
with Lapo Gianni and their three ladies (Dante’s being the first lady
who screened his love), might take a voyage over enchanted seas in
Merlin’s magic barque. Several admirable sonnets, now included in
this group, were formerly attributed to Cino da Pistoia.[14]
(b) The tenzone with Forese Donati forms a little group apart. Its
date is uncertain, but may be plausibly taken as between 1290 and
1296. These sonnets, though not free from bitterness which is
perhaps serious, may be regarded as exercises in that style of
burlesque and satirical poetry to which even Guido Guinizelli had
once paid tribute, and which Rustico di Filippo had made
characteristically Florentine.
(c) Next comes a group of poems, connected with the allegory of
the Convivio, in which an intellectual ideal is pursued with the
passion and wooed in the language of the lover who adores an
earthly mistress. “I say and affirm that the lady, of whom I was
enamoured after my first love, was the most beautiful and most pure
daughter of the Emperor of the Universe, to whom Pythagoras gave
the name Philosophy” (Conv. ii. 16). By some, not entirely
reconcilable, process the donna gentile, who appears at the end of
the Vita Nuova, has become a symbol of Philosophy, and the poet’s
love for her a most noble devotion. The canzone:

Voi che ’ntendendo il terzo ciel movete,

“Ye who by understanding move the third heaven” describing the

conflict in Dante’s mind between this new love and the memory of
Beatrice, deals again with the matter of one of the sonnets of the
Vita Nuova; but the allegory is perhaps an after-thought. It is
commented upon in the second treatise of the Convivio and quoted
in Canto viii. of the Paradiso. The other poems of this group seem
purely allegorical: “By love, in this allegory, is always intended that
study which is the application of the enamoured mind to that thing of
which it is enamoured” (Conv. ii. 16). At first this service is painful
and laborious; and the mystical lady seems a cruel and proud
mistress, as she is represented in the “pitiful ballata”:

Voi che savete ragionar d’Amore,

“Ye who know how to discourse of love,” which is referred to in the

third treatise of the Convivio (iii. 9). But the defect is on the lover’s
own part, and in her light the difficulties which sundered him and her
are dispersed like morning clouds before the face of the sun. This
mystical worship culminates in the supreme hymn to his spiritual
mistress, whose body is Wisdom and whose soul is Love:

Amor che ne la mente mi ragiona,

“Love that in my mind discourses to me of my lady desirously,” which

is the second canzone of the Convivio (quoted in V. E. ii. 6), the
amorous song that Casella was to sing “met in the milder shades of
Purgatory.” It is one of Dante’s lyrical masterpieces. Hardly less
beautiful is the canzone, likewise cited in the De Vulgari Eloquentia
(V. E. ii. 5, II):

Amor, che movi tua vertù dal cielo,

“Love that movest thy power from heaven”; with a mystical

comparison of the workings of love to those of the sun and striking
lines on the supernatural power of the illumined imagination. This
allegorical group may be regarded as closed by the canzone:

Io sento si d’Amor la gran possanza,

“I feel so the great power of love,” in which Dante represents himself
as too young to obtain his lady’s grace, but is content to serve on,
finding the quest of philosophic truth its own reward. This poem has
two commiati (the commiato, or tornata, being the stanza or part of a
stanza, or a few independent lines, added as an address or farewell
at the end of a canzone); both seem to imply that philosophic verse
may be the instrument of political or social reform.[15]
(d) Dante originally held that Italian poetry should only be used for
writing upon love, and therefore, in his younger days, a philosophical
poem would naturally take the form of a love ode. In the Vita Nuova,
he argues “against those who rhyme upon any matter other than
amorous; seeing that such mode of speech was originally found for
speaking of love” (V. N. xxv). His views naturally widened before he
wrote his later canzoni (cf. V. E. ii. 2); but when, lacking inspiration
for a higher lyrical flight or baffled by some metaphysical problem, he
turns to set erring men right in didactic canzoni on some humbler
ethical subject, he represents himself as so doing because out of
favour with his lady or deserted by love. Thus, “The sweet rhymes of
love, which I was wont to seek in my thoughts, needs must I leave”—

Le dolci rime d’amor, ch’i’ solia

—opens the canzone on the spiritual nature of true gentilezza

(inspired in part by Guinizelli), which is expounded in the fourth
treatise of the Convivio, and, although somewhat unequal, contains
one ineffable stanza upon the noble soul in life’s four stages. A
companion poem:

Poscia ch’Amor del tutto m’ ha lasciato,

“Since love has left me utterly,” deals with leggiadria, the outward
expression of a chivalrous soul, and shows the influence of the
Tesoretto of Brunetto Latini. These two canzoni, which contain
transcripts from the Aristotelian Ethics, only here and there become
poetry. In the larger proportion of short lines in the stanza, Dante
seems feeling his way to a more popular metrical form and a freer
treatment, as well as a wider range of subject. The second has
satirical sketches of vicious or offensive types of men, with whom he
will deal more severely in the Commedia.
(e) There are certain lyrics of Dante’s which can hardly admit of an
allegorical interpretation, but are almost certainly the expression of
passionate love for real women. Most notable among these are a
group of four canzoni, known as the rime per la donna pietra, which
are characterised by a peculiar incessant playing upon the word
pietra, or “stone,” which has led to the hypothesis that they were
inspired by a lady named Pietra, or at least by one who had been as
cold and rigid as Beatrice had been the giver of blessing. The
canzone of the aspro parlare:

Così nel mio parlar voglio esser aspro,

“So in my speech would I be harsh, as this fair stone is in her acts,”

shows that Dante could be as terrible in his love as in his hate, and
has a suggestion of sensuality which we hardly find elsewhere in his
poetry. It is indirectly referred to in the Convivio, and quoted by
Petrarch. The other three canzoni of this “stony” group show very
strongly the influence of the Provençal Arnaut Daniel in their form,
and all their imagery is drawn from nature in winter. The sestina:

Al poco giorno e al gran cerchio d’ombra,

“To the short day and the large circle of shade have I come,” is the
first Italian example of that peculiar variety of the canzone which was
invented by Arnaut (V. E., ii. 10, 13). It gives a most wonderful
picture of this strange green-robed girl, her golden hair crowned with
grass like Botticelli’s Libyan Sibyl, in the meadow “girdled about with
very lofty hills.” Less beautiful and more artificial, the canzone:
 Amor, tu vedi ben che questa donna,

“Love, thou seest well that this lady cares not for thy power,” is
likewise quoted with complacency, for its novelty and metrical
peculiarity, in the De Vulgari Eloquentia (ii. 13). And the passion of
the whole group is summed up in the poem on Love and Winter:

Io son venuto al punto de la rota,

“I am come to the point of the wheel,” where, stanza by stanza, the

external phenomena of the world in winter are contrasted with the
state of the poet’s soul, ever burning in the “sweet martyrdom” of
love’s fire. It is the ultimate perfection of a species of poem
employed by Arnaut and other troubadours; another lyrical
masterpiece, anticipating in its degree the treatment of nature which
we find in the Commedia. These four poems were probably
composed shortly before Dante’s banishment, but another canzone
of somewhat similar tone was certainly written in exile—the famous
and much discussed “mountain song”:

Amor, da che convien pur ch’io mi doglia,

“Love, since I needs must make complaint,” apparently describing an

overwhelming passion for the fair lady of the Casentino; its pathetic
close, with its reference to Florence, has been already quoted. The
striking sonnet to Cino da Pistoia about the same time:

Io sono stato con Amore insieme.

“I have been in company with love since the circling of my ninth sun,”
affords further testimony that, at certain epochs of his life, earthly
love took captive Dante’s freewill.
(f) To the earlier years of Dante’s exile belongs the noblest and
most sublime of his lyrics, the canzone:

Tre donne intorno al cor mi son venute,

“Three ladies are come around my heart and are seated without, for
within sits Love who is in lordship of my life.” They are Justice and
her spiritual children; Love prophesies the ultimate triumph of
righteousness, and the poet, with such high companionship in
outward misfortune, declares that he counts his exile as an honour.
While recalling the legend of the apparition of Lady Poverty and her
two companions to St. Francis of Assisi, and a poem of Giraut de
Borneil on the decay of chivalry, the canzone echoes Isaiah (ch. li.).
Its key may be found in the prophet’s words: “Hearken unto me, ye
that know Justice, the people in whose heart is my law; fear ye not
the reproach of men, neither be ye afraid of their revilings.” It was
probably written between 1303 and 1306; its opening lines have
been found transcribed in a document of 1310.[16] To about the
same epoch must be assigned the powerful canzone against vice in
general and avarice in particular:

Doglia mi reca ne lo core ardire,

“Grief brings daring into my heart,” which is cited in the De Vulgari

Eloquentia (associated with another poem of Giraut de Borneil) as a
typical poem on rectitudo, “righteousness,” “the direction of the will”
(V. E. ii. 2). These two canzoni are the connecting link between the
Rime and the Commedia; the first contains the germ of Dante’s
prophecy of the Veltro, his Messianic hope of the Deliverer to come,
who shall make Love’s darts shine with new lustre and renovate the
world; in the second, we already catch the first notes of the saeva
indignatio of the sacred poem. With the exception of the “montanina
canzone” and some sonnets to Cino da Pistoia, Dante wrote few
other lyrics at this period[17]; indeed, one of the sonnets seems to
imply that he had finally turned away from such poetry (da queste
nostre rime) in contemplation of his greater task:

Io mi credea del tutto esser partito,

“I deemed myself to have utterly departed from these our rhymes,

Messer Cino, for henceforth another path befits my ship and further
from the shore.”

3. The “Convivio”
The Convivio, or “Banquet,” bears a somewhat similar relation to
the work of Dante’s second period as the Vita Nuova did to that of
his adolescence. Just as after the death of Beatrice he collected his
earlier lyrics, furnishing them with prose narrative and commentary,
so now in exile he intended to put together fourteen of his later
canzoni and write a prose commentary upon them, to the honour
and glory of his mystical lady, Philosophy. Dante was certainly not
acquainted with Plato’s Symposium. It was from the De Consolatione
Philosophiae of Boëthius that the idea came to him of representing
Philosophy as a woman; but the “woman of ful greet reverence by
semblaunt,” who “was ful of so greet age, that men ne wolde nat
trowen, in no manere, that she were of oure elde” (so Chaucer
renders Boëthius), is transformed to the likeness of a donna gentile,
the idealised human personality of the poetry of the “dolce stil
nuovo”:
“And I imagined her fashioned as a gentle lady; and I could
not imagine her in any bearing save that of compassion;
wherefore so willingly did the sense of truth look upon her,
that scarcely could I turn it from her. And from this imagining I
began to go there where she revealed herself in very sooth, to
wit, in the schools of religious and at the disputations of
 philosophers; so that in a short time, perchance of thirty
months, I began to feel so much of her sweetness, that her
love drove out and destroyed every other thought” (Conv. ii.
13).
The Convivio is an attempt to bring philosophy out of the schools
of religious and away from the disputations of philosophers, to
render her beauty accessible even, to the unlearned. “The Convivio”,
says Dr. Wicksteed, “might very well be described as an attempt to
throw into popular form the matter of the Aristotelian treatises of
Albertus Magnus and Thomas Aquinas.” Dante’s text is the opening
sentence of Aristotle’s Metaphysics: “All men by nature desire to
know”; which he elaborates from the commentary of Aquinas and the
latter’s Summa contra gentiles. He would gather up the crumbs
which fall from the table where the bread of Angels is eaten, and
give a banquet to all who are deprived of this spiritual food. It is the
first important work on philosophy written in Italian—an innovation
which Dante thinks necessary to defend in the chapters of the
introductory treatise, where he explains his reasons for commenting
upon these canzoni in the vernacular instead of Latin, and
incidentally utters an impassioned defence of his mother-tongue,
with noteworthy passages on the vanity of translating poetry into
another language and the potentialities of Italian prose (Conv. i. 7,
10).
In addition to this principal motive for writing the work, the desire of
giving instruction, Dante himself alleges another—the fear of infamy,
timore d’infamia (Conv. i. 2): “I fear the infamy of having followed
such great passion as whoso reads the above-mentioned canzoni
will conceive to have held sway over me; the which infamy ceases
entirely by the present speaking of myself, which shows that not
passion, but virtue, has been the moving cause.” It would seem that
Dante intended to comment upon certain of the canzoni connected
with real women, and to represent them as allegorical; it may be that,
consumed with a more than Shelleyan passion for reforming the
world, he chose this method of getting rid of certain episodes in the
past which he, with too much self-severity, regarded as rendering
him unworthy of the sublime office he had undertaken. And, by a
work of lofty style and authority, he would rehabilitate the man who,
in his exiled wanderings, had “perchance cheapened himself more
than truth wills” (i. 4).
Only the introductory treatise and three of the commentaries were
actually written: those on the canzoni Voi cite ’ntendendo, Amor che
ne la mente mi ragiona, Le dolci rime d’amor. If the whole work had
been completed on the same scale as these four treatises, a great
part of the field of knowledge open to the fourteenth century would
have been traversed in the ardent service of this mystical lady, whom
the poet in the second treatise—not without considerable
inconsistency—represents as the same as the donna gentile who
appeared towards the end of the Vita Nuova (Conv. ii. 2). As it is, the
movements of the celestial bodies, the ministry of the angelic orders,
the nature of the human soul and the grades of psychic life, the
mystical significance and universality of love, are among the subjects
discussed in the second and third treatises. The fourth treatise is
primarily ethical: nobility as inseparable from love and virtue, wealth,
the Aristotelian definition of moral virtue and human felicity, the goal
of human life, the virtues suitable to each age, are among the
themes considered. Under one aspect the Convivio is a vernacular
encyclopaedia (like the Trésor of Brunetto Latini), but distinguished
from previous mediaeval works of the kind by its peculiar form, its
artistic beauty, and its personal note. From the first treatise it is
evident that the whole work had been fully planned; but it is not
possible to reconstruct it with any plausibility, or to decide upon the
question of which of the extant canzoni were to be included, and in
what order. From iv. 26, it may be conjectured that the passionate
canzone, Così nel mio parlar voglio esser aspro (Rime ciii., O. canz.
xii.), was to be allegorised in the seventh treatise; while, from i. 12, ii.
1, iv. 27, it appears fairly certain that the canzone of the three ladies,
Tre donne intorno al cor (Rime civ., O. canz. xx.), would have been
expounded in the fourteenth, where Justice and Allegory were to
have been discussed; and, from i. 8 and iii. 15, that the canzone
against the vices, Doglia mi reca (Rime cvi., O. canz. x.), was
destined for the poetical basis of the last treatise of all. It is thus clear
that the Convivio would have ended with the two canzoni which form
the connecting link between the lyrical poems and the Divina
Commedia. For the rest, it is certain that there would have been no
mention of Beatrice in any of the unwritten treatises. In touching
upon the immortality of the soul (Conv. ii. 9), Dante had seen fit to
end what he wished to say of “that living blessed Beatrice, of whom I
do not intend to speak more in this book.” There seems also good
reason for supposing that the canzone for the beautiful lady of the
Casentino (Rime cxvi., O. canz. xi.), which may be of a slightly later
date than the others, would not have formed part of the completed
work.
Witte and others after him have supposed that the Convivio
represents an alienation from Beatrice; that the Philosophy, which
Dante defines as the amorous use of wisdom, is a presumptuous
human science leading man astray from truth and felicity along the
dangerous and deceptive paths of free speculation. There is,
however, nothing in the book itself to support this interpretation,[18]
and, indeed, a comparison between the second canzone, Amor che
ne la mente mi ragiona, and the first canzone of the Vita Nuova
points to the conclusion that the personification of philosophy is but a
phase in the apotheosis of Beatrice herself. The Convivio is the first
fruit of Dante’s labours to fulfil the promise made at the end of the
book of his youth; his knowledge of literature and philosophy has
immeasurably widened, his speculations on human life and nature
have matured, and his prose style, in its comparative freedom and
variety, its articulation and passages of spontaneous eloquence,
shows a vast progress from that of the Vita Nuova.
There are passages in the Convivio which appear to be
contradicted in the Divina Commedia. One of the most curious is the
treatment of Guido da Montefeltro, who, in Conv. iv. 28, is “our most
noble Italian,” and a type of the noble soul returning to God in the
last stage of life, whereas, in the Inferno (Canto xxvii.), he is found in
the torturing flames of the evil counsellors. Several opinions are
directly or indirectly withdrawn in the Paradiso; but these are to be
rather regarded as mistakes which, in the light of subsequent
knowledge, Dante desired to rectify or repudiate; such as the theory
of the shadow on the moon being caused by rarity and density,
based upon Averroës, and a peculiar arrangement of the celestial
hierarchies, derived from the Moralia of St. Gregory the Great. And,
in the Purgatorio, the poet discards his “dread of infamy,” when he
dares not meet Beatrice’s gaze in the Garden of Eden; he casts
aside the allegorical veil he had tried to draw over a portion of the
past, and makes the full confession which we find in Cantos xxx. and
xxxi. In the fourth treatise, an erroneous sentence attributed to
Frederick II. (in reality a mutilated version of the definition of nobility
given by Aristotle in the Politics) leads Dante to examine the limits
and foundation of the imperial authority, the divine origin of Rome
and the universal dominion of the Roman people, the relation of
philosophy to government; a theme which he will work out more fully
and scientifically in the Monarchia. The result is two singularly
beautiful chapters (iv.-v.); a prose hymn to Rome, an idealised
history of the city and her empire. It is the first indication of the poet’s
conversion from the narrower political creed of the Florentine citizen
to the ideal imperialism which inspires his later works.
It has sometimes been held that portions of the Convivio were
written before exile. Nevertheless, while two of the canzoni were
composed before 1300, it seems most probable that the prose
commentaries took their present shape between Dante’s breaking
with his fellow-exiles and the advent of Henry VII. A passage
concerning Frederick II., “the last emperor of the Romans with
respect to the present time, although Rudolph and Adolph and Albert
were elected after his death and that of his descendants” (Conv. iv.
3), shows that the fourth treatise was written before the election of
Henry VII., in November 1308; while a reference to Gherardo da
Cammino, lord of Treviso (iv. 14), seems to have been written after
his death in March 1306. From the mention of Dante’s wanderings in
exile through so many regions of Italy (i. 3), it has sometimes been
argued that the first is later than the subsequent treatises. It is
tempting to associate the breaking off the work with Boccaccio’s
story of the recovery of the beginning of the Inferno. Be that as it
may, the advent of the new Caesar, Dante’s own return for a while to
political activity, probably interrupted his life of study; and, when the
storm passed away and left the poet disillusioned, his ideals had
changed, another world lay open to his gaze, and the Convivio was
finally abandoned.
 FOOTNOTES:
[10] Io spero di dicer di lei quello che mai non fue detto
d’alcuna: dicer (dire) and detta, have here (as elsewhere in
Dante) the sense of artistic utterance, and more particularly
composition in poetry, whether in Latin or the vernacular. Cf. V. N.
xxv.
[11] Livi has shown that the first documentary evidence of the
existence of the Vita Nuova as a book is found at Bologna in June
1306.
[12] The Sexcentenary Dante admits as authentic one canzone
not included in this series: Lo doloroso amor che mi conduce
(Rime lxviii., O. canz. xvi.*); which is evidently an early
composition.
[13] Cf. Rime xlviii., lvi., lxiii. and the later xcix.; O. son. xlviii.*,
ball. viii., son. I.*, son. xxxvii.*
[14] Note especially Rime lix., lxvi.; O. sonnets lv., xxxviii*.
[15] To this group I would assign the sonnet, Chi guarderà già
mai sanza paura, and the ballata, I’ mi son pargoletta bella e
nova, without attaching any special significance to the fact that
“pargoletta” (“maiden” or “young girl”) occurs also in the canzone,
Io son venuto al punto de la rota, and in Beatrice’s rebuke, Purg.
xxxi. 59.
[16] Cf. G. Livi, Dante suoi primi cultori sua gente in Bologna, p.
24.
[17] Barbi adds to the Rime written in exile the impressive
political sonnet, yearning for justice and peace, Se vedi li docchi
miei di pianger vaghi (of which the attribution to Dante has
sometimes been questioned), and the sonnet on Lisetta, Per
quella via che la bellezza corre, a beautiful piece of
unquestionable authenticity, but which may, perhaps, belong to an
earlier epoch in the poet’s life.
[18] But cf. Wicksteed, From Vita Nuova to Paradiso, pp. 93-
121.
 CHAPTER III
DANTE’S LATIN WORKS
1. The “De Vulgari Eloquentia”
In the first treatise of the Convivio (i. 5), Dante announces his
intention of making a book upon Volgare Eloquenza, artistic
utterance in the vernacular. Like the Convivio, the De Vulgari
Eloquentia remains incomplete; only two books, instead of four, were
written, and of these the second is not finished. In the first book the
poet seeks the highest form of the vernacular, a perfect and imperial
Italian language, to rule in unity and concord over all the dialects, as
the Roman Empire over all the nations; in the second book he was
proceeding to show how this illustrious vulgar tongue should be used
for the art of poetry. Villani’s description of the work applies only to
the first book: “Here, in strong and ornate Latin, and with fair
reasons, he reproves all the dialects of Italy”; Boccaccio’s mainly to
the second: “A little book in Latin prose, in which he intended to give
instruction, to whoso would receive it, concerning composition in
rhyme.”[19]
Book I.—At the outset Dante strikes a slightly different note from
that of the Convivio, by boldly asserting that vernacular in general
(as the natural speech of man) is nobler than “grammar,” literary
languages like Latin or Greek, which he regards as artificially formed
(V. E. i. 1). To discover the noblest form of the Italian vernacular, the
poet starts from the very origin of language itself. To man alone of
creatures has the intercourse of speech been given: speech, the
rational and sensible sign needed for the intercommunication of
ideas. Adam and his descendants spoke Hebrew until the confusion
of Babel (cf. the totally different theory in Par. xxvi. 124), after which
this sacred speech remained only with the children of Heber (i. 2-7).
From this point onwards the work becomes amazingly modern. Of
the threefold language brought to Europe after the dispersion, the
southernmost idiom has varied into three forms of vernacular speech
—the language of those who in affirmation say oc (Spanish and
Provençal), the language of oil (French), the language of sì (Italian).
[20] And this Italian vulgar tongue has itself varied into a number of
dialects, of which Dante distinguishes fourteen groups, none of
which represent the illustrious Italian language which he is seeking.
“He attacks,” wrote Mazzini, “all the Italian dialects, but it is because
he intends to found a language common to all Italy, to create a form
worthy of representing the national idea.” The Roman is worst of all
(i. 11). A certain ideal language was indeed employed by the poets
at the Sicilian court of Frederick and Manfred, but it was not the
Sicilian dialect (i. 12). The Tuscans speak a degraded vernacular,
although Guido Cavalcanti, Lapo Gianni and another Florentine
(Dante himself), and Cino da Pistoia have recognised the excellence
of the ideal vulgar tongue (i. 13). Bologna alone has a “locution
tempered to a laudable suavity”; but which, nevertheless, cannot be
the ideal language, or Guido Guinizelli and other Bolognese poets
would not have written their poems in a form of speech quite
different from the special dialect of their city (i. 15). “The illustrious,
cardinal, courtly, and curial vulgar tongue in Italy is that which
belongs to every Italian city, and yet seems to belong to none, and
by which all the local dialects of the Italians are measured, weighed,
and compared” (i. 16). This is that ideal Italian which has been
artistically developed by Cino and his friend (Dante himself) in their
canzoni, and which makes its familiars so glorious that “in the
sweetness of this glory we cast our exile behind our back” (V. E. i.
17). Such should be the language of the imperial Italian court of
justice, and, although as far as Italy is concerned there is no prince,
and that court is scattered in body, its members are united by the
gracious light of reason (i. 18). This standard language belongs to
the whole of Italy, and is called the Italian vernacular (latinum
vulgare); “for this has been used by the illustrious writers who have
written poetry in the vernacular throughout Italy, as Sicilians,
Apulians, Tuscans, natives of Romagna, and men of both the
Marches” (i. 19).