Total elbow arthroplasty for severe primary elbow osteoarthritis: clinical outcomes of a modified Alonso-Llames approach

Severe primary elbow osteoarthritis (PEOA) is associated with pain, restricted motion, and functional impairment. Total elbow arthroplasty (TEA) is effective for end-stage disease, but conventional posterior approaches may compromise the triceps mechanism. Achieving adequate exposure for osteophyte removal while preserving the extensor mechanism remains challenging. This study aimed to evaluate the clinical efficacy, functional recovery and radiographic safety of total elbow arthroplasty using a modified Alonso-Llames approach for severe PEOA, as well as to confirm its advantages in adequate osteophyte resection and intact triceps mechanism preservation. This retrospective analysis was conducted on 15 consecutive patients with severe PEOA who underwent TEA through a modified Alonso-Llames approach between 2020 and 2023. Based on the classical Alonso-Llames approach, this modification included longitudinal splitting of the anconeus to improve exposure of the proximal ulnoradial structures and routine radial head resection to facilitate thorough removal of anterior and posterior osteophytes. Clinical outcomes were assessed using the Visual Analogue Scale (VAS), Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score, range of motion (ROM), and triceps muscle strength graded by the Medical Research Council (MRC) scale. Radiographic findings and postoperative complications were also recorded. At a mean follow-up of 42.3 months, the VAS score improved from 6.5 ± 1.2 to 0.9 ± 1.0 ( P < 0.05), MEPS increased from 49.0 ± 12.7 to 89.0 ± 8.3 ( P < 0.05), and DASH score decreased from 56.2 ± 5.9 to 17.8 ± 6.4 ( P < 0.05). The flexion-extension arc improved by an average of 68°. Triceps strength recovered to MRC grade 5 in 14 patients and grade 4 in 1 patient, with no postoperative triceps insufficiency. Radiographs demonstrated stable implant positioning without loosening or heterotopic ossification. Only one patient developed transient ulnar nerve irritation that resolved with conservative treatment. The modified Alonso-Llames approach provides sufficient exposure for TEA and thorough osteophyte removal while preserving the triceps mechanism. This technique achieved satisfactory functional recovery in patients with severe PEOA and may represent a useful triceps-preserving strategy for complex elbow arthroplasty.