How does a prior olecranon osteotomy impact the outcome of subsequent total elbow arthroplasty?

Olecranon osteotomy is a common surgical exposure technique used for internal fixation of distal humerus fractures. Unfortunately, retained ulnar hardware and potential osteotomy complications (malunion, nonunion, or extensor mechanism insufficiency) may negatively impact subsequent total elbow arthroplasty (TEA) if needed. Although TEA is a reasonable option for management of failed distal humerus internal fixation or posttraumatic arthritis, little is known about how prior olecranon osteotomy influences TEA outcomes. This study aimed to identify operative considerations, evaluate outcomes, and assess implant survivorship following TEA in patients with a history of prior olecranon osteotomy. Adult patients who underwent primary TEA between 1990 and 2024 with a history of distal humerus open reduction internal fixation with olecranon osteotomy and >2 years of clinical follow-up were identified using our institutional Total Joint Registry Database. Medical records were reviewed to collect demographic information, surgical indications, complications, reoperations, and revisions. Implant survivorship free of revision or resection for any reason, for infection, and for mechanical failure, or loosening was assessed using Kaplan-Meier analyses. Functional outcomes including range of motion and the Mayo Elbow Performance Score were assessed at final follow-up. Twenty-seven patients (mean age 62 years [range 30-86], 70% female) with a mean follow-up of 6 years (range 2-19) were included. The index distal humerus fracture was classified as Arbeitsgemeinschaft für Osteosynthesefragen-Orthopaedic Trauma Association type C in 22 (81%) cases, and the prior olecranon osteotomy had united in most (89%) elbows prior to TEA. Indications for TEA included nonunion (n = 14), post-traumatic arthritis (n = 7), failed fixation (n = 3), malunion (n = 1), refracture (n = 1), and ankylosis (n = 1). Overall rates of complications, nonrevision reoperations, and revision TEA were 37%, 11%, and 26%, respectively. Aseptic loosening (n = 3), infection (n = 2), and component failure (n = 2) accounted for all revisions. Ten-year survivorship free of revision or resection for any reason was 76%, for infection was 89%, and for mechanical failure or loosening was 85%. At final follow-up, patients achieved satisfactory flexion (140°), extension (31°), supination (60°), and pronation (67°), as well as a mean Mayo Elbow Performance Score of 78 ± 17, indicating good elbow function. TEA following prior olecranon osteotomy was associated with a 76% rate of survivorship free of revision or resection for any reason at 10 years. Aseptic loosening, infection, and component failure accounted for all revision indications. Despite slightly inferior outcomes compared to those following primary TEA, underscoring the increased complexity of the procedure following prior olecranon osteotomy, these findings suggest TEA can reliably restore function and achieve acceptable implant survivorship in this context.