Results after 562 total elbow replacements: A report from
the Norwegian Arthroplasty Register
Bjørg-Tilde S. Fevang, PhDa,b,*, Stein A. Lie, PhDb,d, Leif I Havelin, PhDb,c, Arne
Skredderstuen, MDb, Ove Furnes, PhDb,c
aDepartment of Rheumatology, Haukeland University Hospital, Bergen, Norway
bThe Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
cSection for Orthopedic Surgery, Department of Surgical Sciences, University of Bergen, Bergen, Norway
dDepartment of Health, University Research Bergen, Bergen, Norway
Background: The aim of this study was to give results of elbow arthroplasty for a relatively large popu-
lation and compare different prosthesis brands and different patient subgroups.
Methods: Between 1994 and 2006, 562 total elbow replacement operations were reported to the Norwe-
gian Arthroplasty Register. Revisions of prostheses were shown using Kaplan-Meier failure curves, and
risk of revision was calculated using Cox regression analysis.
Results: The overall 5- and 10-year failure rates were 8% and 15%, respectively. There were only minor
differences between the different implants. Patients who developed traumatic arthritis after fracture had the
worst prognosis compared with inflammatory arthritis (P ¼ .005). Risk of revision was also increased when
the ulnar component was inserted without cement (P ¼ .02.)
Conclusions: Good results in terms of prosthesis survival were obtained with total elbow arthroplasty,
although results were worse than for knee- and hip arthroplasties. The best results were achieved in patients
with inflammatory arthritis.
Level of evidence: Level 2; prospective cohort study.
? 2009 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Elbow arthroplasty; prosthesis survival; national arthroplasty register; inflammatory
arthritis; osteoarthritis; acute elbow fracture; fixation method
The body of literature on elbow arthroplasty is
increasing, but most studies include reports of a single
prosthesis. No randomized study comparing different
brands has, to our knowledge, been published. A systematic
review of the 8 most frequently used total elbow prostheses
was published in 2004.37Loosening, infection, and dislo-
cation were the most common complications after total
elbow replacement (TER) but with different distribution for
different prosthesis brands.
A few studies give survival results for elbow prostheses,
and 10-year survival of 69% to 88% has been repor-
ted.19,29,34,36The functional results have been good or
excellent in about 80% of patients, and better for sloppy-
hinged devices than with unlinked or fixed-hinged
implants.17The aim of the present study was to present
long-term results with total elbow arthroplasty in terms of
All studies published by the Norwegian Arthroplasty Register have been
approved by the Regional Committee for Medical Research Ethics and the
Data Inspectorate of Norway.
*Reprint requests: Dr B. T. Fevang, The Norwegian Arthroplasty
Register, Department of Orthopedic Surgery, Haukeland University
Hospital, Møllendalsbakken 11, 5021 Bergen, Norway.
E-mail address: email@example.com (B.-T. S.
J Shoulder Elbow Surg (2009) 18, 449-456
1058-2746/2009/$36.00 - see front matter ? 2009 Journal of Shoulder and Elbow Surgery Board of Trustees.
survival analyses in different subgroups of patients and for
different prosthesis brands. Furthermore, we wanted to
analyze trends in the use of elbow prostheses during a
Materials and methods
Data for the present study were obtained from the Norwegian
Arthroplasty Register (NAR), which was established in 1987 as
a hip arthroplasty register. From 1994, the register was extended to
include data for replacements of other joints.9The NAR receives
information on elbow arthroplasties from all hospitals in Norway
at which the procedure is performed. Information on demo-
graphics, date of primary surgery, diagnosis, prosthesis brand, the
use of thrombosis prophylaxis and antibiotics, fixation method,
complications, and date and cause of revision surgery is derived
from the forms filled in by the operating surgeon.7The
completeness of the NAR was analyzed in an article by Espehaug
et al.5They found that 87% of all primary elbow arthroplasties
were reported to the NAR. Data on functional outcome are not
recorded in the register and will not be considered in this article.
Nine different brands of prostheses were registered during the
study period. Among these, 5 were unlinked (nonconstrained) and
4 were hinged semiconstrained (Table I). In contrast to the con-
strained prostheses that have fixed hinges, the hinged semicon-
strained prostheses allow some degree of varus-valgus and
rotational laxity. The unlinked prostheses are not hinged and
generally may not be used in patients with significant bone loss
due to trauma or arthritis mutilans. In these cases, the ligaments
and muscles are not intact, and increased support is needed to
obtain stability of the joint.
A description of designs and a picture of 5 of the prostheses
(Coonrad-Morrey [Zimmer, Warsaw, IN], GSB III [Zimmer],
Kudo [Biomet Ltd, South Glamorgan,UK], Norway, Souter-
Strathclyde) is given in an article from 2004.37The GSB III is
a semiconstrained cemented prosthesis with metal humeral and
ulnar components, and the articular surfaces are coated with
polyethylene.8The Kudo prosthesis is nonconstrained, with
a humeral component made of cobalt-chromium alloy, and half of
the surface of the stem has a porous coat of titanium alloy.15The
ulnar component is metal backed and may be inserted with or
without cement. Only 5 patients in this study had a Kudo unce-
mented ulnar component. The iBP (Biomet Inc, Warsaw, IN) is
a nonconstrained prosthesis with a cobalt chrome humeral
component and an ulnar component of titanium alloy with an
ArCom polyethylene bearing (Biomet). A linked prosthesis
otherwise resembling the iBP is the iBP Reconstructive Elbow.
The Discovery Elbow (Biomet Inc) is a semiconstrained prosthesis
with a plasma sprayed titanium alloy humeral and ulnar
The NESimplavit Elbow System (Implantcast, Buxtehude,
Germany) is a nonconstrained joint replacement. The dimensions
and design are the same as the Norway prosthesis, but the ulnar
and humeral components are made of cast cobalt-chromium-
molybdenum alloy instead of titanium (used for the Norway
prosthesis). The bobbin articulates against a ceramic-coated axle
(titanium nitride coating). The system is for cemented use only.
The fixation method was defined as either with or without the
use of cement (containing antibiotics or not). In 7 cases, the
fixation method (with or without cement) was not reported for one
or both components.
Ninety patients had elbow replacements bilaterally during the
study period. In these patients, each replacement procedure was
considered a separate case. A revision was defined as the removal
or exchange of a part of or the whole implant. No bushing
exchange procedures were reported, but this procedure might have
been registered as an exchange of part of the prosthesis. The
observation time was the time from primary elbow replacement
until revision or until end of study or death. The date of death was
obtained from Statistics Norway (www.ssb.no/english/).
In Table II and Figure 1, rheumatoid arthritis, psoriatic
arthritis, and ankylosing spondylitis were grouped and categorized
as inflammatory arthritis. Several causes of revision could be
given in one patient (Table III). However, pain was only registered
as the cause of revision in cases where this was the only recorded
cause. Because no cases were revised due to implant fracture,
‘‘fracture’’ as the cause of revision means periprosthetic fracture
Prosthesis brands used during the study period
No. of hospital operations
Hospitals using the prosthesis, No.
TER, Total elbow replacement.
)The prostheses were either nonconstrained (unlinked) prostheses or hinged semiconstrained prostheses.
yDescribed in article by Van der Lugt.
zNESimplavit Elbow System.
450 B.-T. S. Fevang et al.
The t test was used to compare continuous variables (age). The
significance level was set to 5% and all P values were 2-tailed.
Median follow-up (observation) time was calculated using the
reverse Kaplan-Meier method. Kaplan-Meier failure curves with
revision for any reason as the end point were given for patient
subgroups, and differences in revision rate between groups were
tested using the log-rank test. The failure curves were dis-
continued when fewer than 10 patients were at risk.
Cox multiple regression analysis was used to calculate relative
risk (RR) of revision according to prosthesis brand, elbow disease,
the use of cement for fixation, age, gender, and year of primary
operation (Table II). All RRs were adjusted for the other variables
in the analysis.
The number of revisions due to specific causes such as loos-
ening or luxation was small (Table III). Because of the small
number of events, with occasional zeros, models for exact Cox
regression were set up. The statistical program LogXact (Cytel
Inc, Cambridge, MA) was used according to Samuelsen.30The
models were adjusted for sex and age, prosthesis brand, shoulder
disease, and the use of cement for fixation of the distal component.
The results of these analyses are presented only in the text.
Poisson regression analysis was used to analyze trends in the
incidence of total elbow arthroplasties. These analyses were per-
formed based on yearly population rates for the Norwegian pop-
ulation obtained from Statistics Norway. The P values given in the
text describing Figure 1, B, were derived from these Poisson
analyses. However, the figures show absolute numbers, not inci-
dences. All analyses, except the exact regression analyses, were
performed using SPSS 13.0 software (SPSS Inc, Chicago, IL).
During the period 1994 to 2006, 562 total elbow arthro-
plasties were performed in 452 women and 110 men. The
mean age at surgery was 62 years. Nine different prosthesis
brands were used during the study period (Table I). The
most commonly inserted implants were Norway, Kudo, and
iBP, all used in more than 100 cases. These were used in
about 10 different hospitals each, some of which had
a relatively large volume of operations (Table I). The
unlinked prostheses, Kudo and Norway, were the most
commonly used brands during the first 6 years, but from
2000, they were gradually replaced by GSB III, iBP, and
NESimplavit (Figure 1, A). No statistically significant
difference was found in the age and gender distribution of
the patients receiving the 5 most commonly used prostheses
(Table IV; P ¼ .25 for age and P ¼ .13 for gender).
Rheumatoid arthritis was the most common diagnosis in
patients undergoing TER and was seen in 85% (Table IV).
Survival analysis by Kaplan-Meier and Cox regression for revision after total elbow arthroplasty
RevisionsF5, % (95% CI)y
F10,% (95% CI)y,z
RR (95% CI)P
Year of surgery
50553 8 (6-11)15 (11-20)
CI, Confidence interval; IA, inflammatory arthritis; OA, osteoarthritis; RR, relative risk.
)Only patients with one of 5 prosthesis brands and with 3 diagnoses were included in the analysis.
yF5and F10refer to unadjusted Kaplan-Meier 5-year and 10-year failure (revision) rates with 95% confidence intervals. No percentage was given when
less than 10 patients were at risk. RR is relative risk of revision derived from the Cox model.
zIn some subgroups, the observation time was less than 10 years and the 10-year failure rate could not be given.
xIncludes rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. The patients with acute fractures were excluded from the analysis.
))Fixation of ulnar prosthesis component. Cement with and without antibiotics were grouped.
Results after 562 total elbow replacements451
Osteoarthritis, acute fracture, and fracture sequela were
other less frequent diagnoses leading to TER. From 1994 to
2006 the incidence of TER significantly decreased (P <
.001, Figure 1, B). The decrease was due to a fall in the use
of elbow prostheses among patients with rheumatoid
arthritis (P < .001).
Median follow-up time was 6.2 years (95% confidence
interval [CI], 5.7-6.7 years) for all patients, but varied from
2.9 years for the iBP to 8 years for the Kudo and to 8.9
years for the Norway prostheses (Table III). A total of 58
revisions were required. The major cause was aseptic
loosening of the humeral or ulnar component, followed by
luxation, instability, and fracture (Table III). Only 3 patients
required a revision operation due to deep infection.
Table III also reports major causes of revision for the most
commonly used prosthesis brands.
The procedure at revision was exchange of the ulnar
component in 7 cases, exchange of the humeral component
in 9, and exchange of the entire prosthesis in 21. Removal
without replacement of the implant was done in 18 cases, of
which the whole implant was removed in 16 and only the
humeral component in 2. A new prosthesis was inserted
during a later procedure in both the latter cases and in 14 of
the 16 instances where the whole prosthesis was removed.
This 2-stage procedure was performed in the 3 patients with
deep infection as well as for some patients with fractures,
luxations, or instability.
The overall 5- and 10-year failure rates for all elbow
arthroplasties were 8% and 15%, respectively (Figure 2, A
and Table II). Failure curves for the 5 most commonly used
total prosthesis brands are shown in Figure 2, B. The 5- and
10-year survival rates were 6% and 15% for the Kudo and
4% and 11% for the Norway prosthesis. In the adjusted
model, however, only the NESimplavit had a significantly
increased risk of revision compared with the Kudo (RR,
4.7; 95% CI, 1.2-18.2; Table II). The elbow disease influ-
enced the risk of revision. Patients with sequela after
fractures had the worst prognosis, with a RR of 5.8
compared with inflammatory arthritis (95% CI: 1.7-19.7,
Cement was used for fixation of both components of 391
total prostheses, only the ulnar component was cemented in
135, and only the humeral component was cemented in 7.
In 22 cases, none of the components were fixated with
cement. Failure curves according to cementation of the
humeral (Figure 3, A) and ulnar (Figure 3, B) components
showed that only cementation of the ulnar component
influenced prosthesis survival. Although the use of cement
for the humeral component did not influence survival
(P ¼ .57, Figure 3, A), cementation of the ulnar component
was associated with increased
(Figure 3, B). The risk of revision without cement fixation
of the ulnar component was 3 times that of patients with
a cemented ulnar component (RR, 3.3; 95% CI, 1.3-8.4,
Table II). Altogether, 27 patients received an uncemented
ulnar component, comprising 16 iBP, 5 Kudo, 3 GSB III, 3
NESimplavit, and 1 Norway.
When the risk of revision due to specific causes such as
loosening of prosthesis components or luxation (Table III)
was analyzed, fewer revisions were required due to fracture
among patients with the GSB III prostheses compared with
the other 4 most commonly used brands (P ¼ .03).
Otherwise, no statistically significant differences in the risk
of revisions due to specific causes were found.
The main findings of the present study were the overall 5-
and 10-year failure rates of 8% and 15%, similar to those
reported by Ikavalko et al,12who had 96% survival at 5
years and 84% at 10 years. Other studies have reported
survival in the same range34,36or lower.16,29In all of these
studies, the Souter-Strathclyde prosthesis was used. This
prosthesis was used in only 2 patients in our study, but
Year of surgery
20062005 20042003 200220012000 1999 19981997 19961995 1994
Year of surgery
200620052004 2003200220012000 19991998 199719961995 1994
Total elbow prosthesis
prosthesis brand. (B) Annual total elbow replacement according to
diagnosis. IA, Inflammatory arthritis; OA, osteoarthritis.
(A) Annual total elbow replacement according to
452B.-T. S. Fevang et al.
because the Norway, Kudo, and iBP prostheses are also
nonconstrained prostheses, and because most survival data
are given for the Souter-Strathclyde prosthesis, we believe
our results may be comparable with these studies. An
overall revision rate of 13% was given in a review article
describing more than 3000 elbow arthroplasties; however,
this was not related to a specific time after the primary
surgery, although the mean follow-up time was 60
The failure rates were somewhat different for the main
prosthesis brands. The NESimplavit had a higher risk of
revision compared with the Kudo. The failure curves might
indicate better results with the GSB III, but the Cox
analysis showed no difference in survival compared with
the Kudo (P ¼ .58, Table II). The median follow-up time
varied for the different prostheses, which may have influ-
enced the results to some degree. The NESimplavit pros-
thesis has only been used since 2001, and the results may
have been influenced by the surgeons’ limited experience
with the prosthesis during the first years. There are only
minor differences between the Norway and the NESim-
plavit prosthesis, making it less likely that the inferior
results are due to the NESimplavit prosthesis design. We
believe that more experience with the prosthesis is neces-
sary before any conclusion about this prosthesis can be
Uncemented ulnar components were associated with an
inferior prognosis, which might have influenced the overall
results for the iBP because it was mainly this prosthesis that
had uncemented ulnar components (n ¼ 16). Although the
Cox regression analysis indicated such a trend, the risk
of revision was not significantly higher than for the Kudo
(P ¼ .10).
Early designs of implants for TER had rigid hinges, and
the results were rather poor due to loosening.3,20,28This
caused the development of unconstrained (unlinked) and
Causes of revision in total elbow replacement
Aseptic loosening, No.
Median follow-up, yHumeralUlnar Luxation, No.Instability, No.Fracture, No.z
6.0 1917 14
TER, Total elbow replacement.
)Total number of primary operations.
yTotal number of revisions for any cause. Several reasons could be given for one revision (ie, loosening of both ulnar and humeral component).
zFracture is defined as a periprosthetic fracture.
xAll TERs include all patients with all the 9 prosthesis brands. In addition to the revisions due to the given 5 causes, the following causes of revision
were given: incorrect axis (4), deep infection (3), pain (3), and other (6).
Demographics and diagnosis in patients undergoing total elbow replacement according to prosthesis type
Norway VariableKudo IBPNESimplavit GSB III
Age, mean (SD), y
Gender (% women)
Diagnosis, No. (%)y
SD, Standard deviation.
)All includes all patients with all prostheses. The characteristics are only given for the 5 most common prosthesis brands; consequently, the sum of
these does not equal the numbers given for all prostheses.
yMore than one diagnosis could be registered.
Results after 562 total elbow replacements453
hinged semiconstrained implant designs. Some studies of
the unlinked prosthesis Souter-Strathclyde report compa-
rable survival rates with those of the Kudo and Norway in
our study.12,34One report on 50 Kudo prostheses showed
better results than we found for the Kudo prosthesis,
reporting survival of 90% at 16 years.33
A major cause of revision after elbow arthroplasty is
aseptic loosening.12,17,29This was also, by far, the most
common cause of revision in our study. Furthermore,
previous publications report a rather high frequency (up to
9 percent) of infections leading to revision.12,17,29In our
study, only 3 elbows were revised due to deep infection.
One reason for this may be that only deep infections
leading to removal or exchange of prosthetic parts were
reported to the NAR. Consequently, soft-tissue revision
procedures not involving the prosthesis were not registered.
The same was the case with the studies of Rozing29and
Ikavalko et al,12whereas the study of Little et al17includes
Years after operation
Years after operation
for the 5 most frequently used prostheses.
(A) Overall failure curve for total elbow replacement. The shaded area provides the 95% confidence interval. (B) Failure curves
Years after operation
Years after operation
Revisions according to cement fixation for the (A) humeral component and (B) ulnar component.
454B.-T. S. Fevang et al.
several different studies, and the definition of deep infec-
tion was not necessarily infection leading to revision.
Furthermore, there may have been revision procedures due
to deep infection that were not reported to the register
because 87%, not 100%, of all elbow prosthesis operations
were reported to the NAR.
We found that the risk of revision was higher for patients
operated on due to fracture sequela compared with those
with inflammatory arthritis. Similar findings were reported
in a study of 95 patients in which patients with inflamma-
tory arthritis had the best prognosis.14One reason for the
better results in inflammatory arthritis patients may be that
they have a lower level of activity due to their generalized
inflammatory joint disease, thus there is less strain on their
In some previous studies, the ulnar component has been
said to be the component most at risk of loosening,16,25,33,35
whereas others found more loosening of the humeral
component.1,33We found revision due to loosening of the
humeral component to be equally as frequent as ulnar
component loosening. In one recent study, revision
occurred more often in elbows with uncemented compared
with cemented ulnar components.35We also found that the
use of uncemented ulnar components was associated with
increased failure rates.
The incidence of total elbow arthroplasty decreased
during the study period. We believe an improvement in the
treatment for rheumatoid arthritis is the main cause of this
development, because an opposite trend has been docu-
mented for knee and hip arthroplasties mainly performed in
patients with osteoarthritis.7,10,13,18,22,24,26,31The finding is
in accordance with a general trend toward less arthroplasty
surgery in patients with inflammatory arthritis.6
Most previous studies on elbow arthroplasty only
include patients with rheumatoid arthritis or inflammatory
arthritis.2,16,23,27,32,36One study had a distribution of
diagnoses resembling that of our study,14with about 85%
inflammatory arthritis. A few articles report results on TER
in patients with osteoarthritis or fracture, but the patient
populations are small and survival analyses are lack-
ing.4,11,21In our study, there seemed to be an increase in the
insertion of TER due to diagnoses other than inflammatory
arthritis. This may in time lead to increasing use of TER.
In conclusion, we found that in a national study of 562
patients, the total revision rate was 8% at 5 years and 15%
at 10 years, which is an inferior result compared with hip
and knee arthroplasty but in the same range as other
reported elbow arthroplasty series. The diagnosis that
resulted in the procedure and the fixation method of the
ulnar component influenced the revision rate.
We thank the Norwegian surgeons for providing data to the
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