Complications of total elbow arthroplasty: experience with 622 cases and implant developments

Introduction Total elbow arthroplasty (TEA) is increasingly used for the treatment of advanced elbow conditions with the rate of adverse events after surgery being high.

The objective was to analyze the spectrum and causes of complications following TEA depending on the biomechanical implant design and evaluate the effect of humeral trochlear resection on hand grip strength.

Material and methods A retrospective non-randomized cohort study of 622 primary and revision TEA procedures was performed between 2002 and 2025. Depending on the biomechanical principle of implant fixation, patients were stratified into two groups to include constrained implants (ESI, n = 404) and semi-constrained implants (Zimmer Coonrad – Morrey, Conmet, Treza, Logeeks, n = 218). Clinical and radiological data, intraoperative findings during revisions, and instrumented dynamometry results (n = 80) were analyzed preoperatively and at 6 weeks of surgery. Statistical analysis was performed using non-parametric tests (Mann – Whitney U, Wilcoxon, Chi-square).

Results The overall complication rate was 7.0 % (44/622). Aseptic loosening of TEA was more common for constrained implants (4.5 %, 18/404) due to stress concentration at the bone-cement interface. Mechanical failure of the hinge joint/polyethylene wear (3.2 %, 7/218) was the leading cause of revision in the semi-constrained group. Resection of the humeral trochlea had no clinically significant effect on hand and pinch grip strength (p > 0.05).

Discussion Existing TEA constructs exhibit a predictable complication profile directly related to their biomechanical design. Optimizing outcomes is associated with advanced surgical techniques and a transition to new-generation implants considering the complex three-dimensional kinematics of the joint and providing balanced load transfer with a reinforced, wear-resistant hinge system.

Conclusion The complication profile after TEA was implant dependent. Constrained systems could predispose to aseptic loosening, and semi-constrained systems can be associated with fatigue wear of the hinge. Trochlear resection did not compromise the hand strength. Future implant developments should focus on optimization of controlled varus-valgus laxity (5–7°), reinforcing the hinge coupling mechanism, considering the anatomical torsion of the distal humerus.

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