The treatment of complex radial head fractures remains a challenge for the orthopedic surgeon. Novel implants and improved surgical techniques have made reconstruction of the radial head with open reduction and internal fixation possible in most cases. However, extremely comminuted radial head fractures with associated instabilities still require replacement of the radial head with a prosthesis to allow rehabilitation with early motion of the elbow, and thereby optimizing the functional results of these potentially devastating injuries. In this article we discuss the surgical considerations related to radial head replacement, encompassing the indications for radial head arthroplasty, implant selection, surgical technique, rehabilitation protocols, and complications related to radial head prosthesis.