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Total elbow arthroplasty revision rates have been increasing over time due to the increasing use of the procedure with the accompanying increase in complications. The most common complications that typically require revision surgery include aseptic loosening, periprosthetic fractures, infection, and component failure. The associated instability has an overall revision rate reported to be as high as 13%. One important factor when performing a revision surgery is bone quality and bone loss; this represents a challenge during the clinical decision-making process. Currently, there are several strategies used to address bone loss such as arthrodesis, resection arthroplasty, impaction grafting, allograft-prosthetic composite reconstruction, and custom prostheses. The aim of this review article is to provide a comprehensive review of the current strategies to improve diagnosis of failed total elbow arthroplasty and improve management and outcomes of this patient population.

Background: Aseptic loosening, polyethylene wear, and mechanical failure have limited the use of total elbow arthroplasty (TEA) in physically demanding patients. Newer implant designs have been introduced to improve mechanical performance. The purpose of this study was to report the results obtained after implantation of the Nexel TEA. Methods: Over a 3-year period, 2 surgeons implanted a total of 35 consecutive Nexel primary TEAs. The average patient age was 65 years, and standard TEA indications were utilized. Elbows were evaluated for pain, motion, the Mayo Elbow Performance Score, complications, and reoperations. Results: Twelve elbows underwent a revision surgery with removal of either a part of or all Nexel components at an average of 2.2 years. All revision surgeries performed at our institution revealed gross loosening of the component(s). Metallic debris and periprosthetic fractures were present in 45% and 50% of cases, respectively. Radiographic evaluation of existing components revealed humeral component loosening and periprosthetic fractures in 2 and 4 elbows, respectively. Overall, 17 of 35 (50%) elbows underwent reoperation, and 20 of 35 (60%) elbows sustained at least 1 postoperative complication. Conclusion: Primary TEA with implantation of this implant was associated with an unacceptably high rate of early implant loosening, periprosthetic fracture, and reoperation. We hypothesize that this early unexpected mechanical failure could be explained by both the utilization of a titanium-on-polyethylene bearing surface and a more posterior center of rotation causing premature anterior impingement with flexion leading to failure of the bonding interface, secondary titanium particle shedding, polyethylene wear, and osteolysis.

Posttraumatic elbow arthritis presents a difficult problem in young patients. Total elbow arthroplasty may not be suited to the functional demands placed on the prosthesis in younger, more active individuals. Interposition arthroplasty is a useful nonprosthetic alternative in these patients. Various biologic materials have been employed as an interpositional graft, with Achilles tendon allograft being the preferred material. Successful outcomes have been reported in 26% to 94% cases, with the best results in patients with posttraumatic arthritis with stiffness and no underlying instability. Poor prognostic factors associated with this procedure include malalignment and pre- and postoperative instability. Use of a hinged-distraction device to allow immediate postoperative range of motion while protecting the graft may further improve results. In those patients where postoperative instability occurs or where results deteriorate with time, stability and pain relief can be salvaged by conversion to a semiconstrained total elbow arthroplasty.