Updated: 7/1/2020

Revision Total Elbow Arthroplasty

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Introduction
  • Overview 
    • revision total elbow arthroplasty (TEA) is most commonly performed due to aseptic loosening, periprosthetic infection, or periprosthetic fracture with loose implants
      • treatment depends on etiology of TEA failure
  • Epidemiology 
    • incidence
      • overall lifetime revision rate of TEA is 13%
      • the current overall outcomes and survival rates of TEA shows overall 5, 10, 15 and 20 year rates of 92%, 81%, 71% and 61%
    • demographics
      • initially, the primary patients undergoing TEA were those with rheumatoid arthritis
      • with advent of anti-rheumatics, a major proportion of patients undergoing TEA are now post-traumatic
    • risk factors for overall TEA failure
      • smoking
      • significant medical co-morbidities 
      • non-compliance with activity restrictions
      • non-constrained system (dislocation)
      • highly constrained system (loosening)
  • Pathophysiology 
    • 5 modes of TEA failure requiring revision
      • infection (initially ~8% but since advent of DMARDs, rates have dropped to ~3%)
        • substantially higher than arthroplasty of other joints
        • most common pathogen is s.aureas (~40%) followed by s.epidermidus (30-35%)
          • worse outcomes with s.epidermidus 
        • risk factors for TEA infection
          • higher prevalence in patients with rheumatoid arthritis on steroids
          • decreased thickness of soft tissue envelope
          • prior elbow infection
          • prior elbow surgery
          • psychiatric illness
      • periprosthetic fracture (5%) 
        • intra-operative
          • can occur during bone preparation, reaming and implantation
        • post-operative
          • non-compliance with activities
          • ground-level falls
      • aseptic loosening (15%) 
        • higher rates associated with cementation and highly constrained systems
        • can result from anterior impingement of coronoid being driven into anterior humeral flange during maximal elbow flexion 
      • instability
        • commonly due to unconstrained TEA systems 
      • component failure (15%)
        • most commonly due to bushing wear  
          • most common in younger patients or those with significant pre-existing deformity
  • Prognosis 
    • prognostic variable 
      • depends on etiology of TEA failure, medical co-morbidities and remaining ulna and humeral bone stock
Classification
 
 
Mayo (O'Driscoll & Morrey) Classification of Periprosthetic fracture  
Type  Characteristics Treatment 
Type I Periarticular fracture involving the humeral condyle or olecranon. Caused by osteolysis around hinge components and distracting forces from muscle attachments 

Undisplaced - Immobilization /soft tissue repair is sufficient to achieve fibrous union (Rigid fixation not required).

Displaced - ORIF with heavy nonabsorbable sutures or tension band wiring (if limited periprosthetic bone)

Type II

Fracture along length of humeral or ulnar stem.

 Subtypes:

    II1: well-fixed implant

    II2: loose implants, good bone stock

    II3: loose implants, severe bone loss


II1: ORIF with component retention +/- strut allograft 

II2: Revision arthroplasty using long-stem prosthesis ± strut allograft and impaction bone grafting. Locking plates/ cerclage wires may be added for added stability.  

II3: Require revision arthroplasty with extensive allograft supplementation. Often times require resection arthroplasty

Type III Distal to prosthesis. Treated like routine fractures. Radiographs/CTs to ensure implants are not loose, cement mantle not cracked.

If implants are well-fixed, immobilization for humerus and ORIF for ulna. 

If implants are loose, treat as Type II2 fractures.

 
Presentation
  • Symptoms 
    • squeeking
      • elbow crepitus or "squeaking" sound with motion
    • pain
      • elbow pain
        • pain at night or rest is a red flag for infection
      • swelling
    • stiffness
      • decrease motion after a period of normal motion
        • progressive loss of motion without identifiable cause is red flag for infection
  • Physical exam 
    • inspection 
      • erythema/sinus tract in the setting of infection
      • diffuse tenderness
      • elbow swelling
      • deformity 
        • in cases of significant bushing wear
    • motion 
      • painful and limited range of motion
        • crepitus/squeaking during motion
Imaging
  • Radiographs 
    • recommended views 
      • AP and lateral of humerus, elbow, and forearm
    • findings 
      • periprosthetic component loosening
        • early unexplained loosening concerning for infection
      • periprosthetic humeral or ulnar fractures
      • polyethylene bushing wear
        • angle of intersection between the ulnar implant in relation to the humeral implant is measured 
        • mild-moderate bushing wear is considered when the angle > 10 degrees 
  • CT
    • indications
      • assess for peri-prosthetic osteolysis or loosening
      • can be useful to determine if cement mantle is intact or broken in cases of peri-prosthetic fracture
  • MRI 
    • indications 
      • to evaluate for abscess or soft tissue infection
    • views 
      • obtain with metal subtraction 
      • obtain with contrast
Studies
  • Diagnosis
    • there are no definitive tests to reliably diagnose periprosthetic elbow injection
      • high clinical suspicion necessary for diagnosis of infection
  • Serum Labs
    • ESR, CRP, WBC are usually elevated 
    • IL-6 and alpha defensin have not been previously studied for utility in PJI of the elbow
  • Elbow arthrocentesis
    • no documented acceptable synovial WBC count indicative of infection
    • positive culture generally indicative of chronic infection
      • very high PPV and very low NPV (a negative aspiration should NOT be used to rule out infection)
  • Intraoperative analysis 
    • intraoperative histologic analysis 
      • most effective way of diagnosing TEA infection
      • specificity of 93% and NPV of 90%, sensitivity of only 51%
    • intraoperative cultures
      • cultures negative 10% of the time in cases of infectious TEA
        • negative cultures more common in chronic infections (~15%) compared to acute infections (3%
Treatment 
  • Nonoperative 
    • immobilization, functional elbow brace
      • indications 
        • type I humeral condylar or olecranon fractures with stable prosthesis
        • type III humeral fractures with stable implants
        • patients who are not candidates for surgery (medical frailty, noncompliance, frequent falls)
      • length
        • length of immobilization depends on location of fracture (2-4 weeks)
      • type
        • transition to sarmiento (for Type III humerus fractures) or functional elbow brace (for Type 1 fractures)
  • Operative 
    • irrigation and debridement, bushing exchange, component retention
      • indications 
        • crepitus, squeaking +/- elbow pain with range of motion with stable implants and no evidence of infection (significant bushing wear)
        • acute peri-prosthetic joint infection (presenting < 90 days from surgery)
      • outcomes
        • in appropriate candidates without signs of infection, 75% result in good results at 5 year followup following isolated bushing exchange
        • in cases of acute infection, I&D and component retention is 63% effective at eradicating acute infections
          • only 31% effective in management of chronic infections
    • open reduction and internal fixation, component retention, +/- fracture excision, +/- strut allograft
      • indications
        • type I peri-articular olecranon fractures
        • type II1 fractures
        • type III fractures of the ulna
      • outcomes
        • 80-90% patients have no complications following isolated ORIF or excision for selected fractures
    • single stage revision TEA, +/- ORIF and allograft 
      • indications
        • type II2 periprosthetic humeral shaft or ulna fractures
        • aseptic loosening
      • outcomes
        • only 66% affective for errdicating chronic TEA infection
    • component explantation and 2-stage revision TEA
      • indications 
        • Mayo II2
        • infected periprosthetic TEA 
      • outcomes
        • success rate of eradicating chronic infection is 90% with 2-stage revision TEA (compared to 66% for single-stage)
    • resection arthroplasty  
      • indications
        • salvage procedure for treatment resistant PJI in patients who are unable to go multiple surgical procedures, have severe bone loss, and severely compromised soft tissue envelope
        • Mayo II3 periprosthetic fractures not amendable for reconstruction
      • outcomes
        • 71% effective in completely eradication infection
        • leads to the lowest functional scores (based on Mayo Elbow Performance score
Techniques
  • Irrigation and debridement, bushing exchange, component retention 
    • approach
      • use prior surgical approach if feasible to allow adequate exposure to the elbow joint
    • soft tissue work
      • most authors advocate for ulnar nerve exploration/decompression in presence of ulnar nerve symptoms
        • if nerve is not symptomatic, it can be identified proximally and protected throughout rest of case
      • a thorough debridement of any necrotic or infected soft tissue should be performed with care to preserve a soft tissue envelope for closure.
    • instrumentation
      • humerus and ulnar components should be uncoupled
      • both humeral and ulnar components should be inspected for integrity, loosening and rotation
      • a polyethylene bushing exchange should then be performed
  • Open reduction and internal fixation, component retention, +/- fracture excision, +/- strut allograft, 
    • approach
      • for humeral fractures
        • posterior paratricipital muscle sparing approach
      • for ulna fractures
        • posterior approach to elbow with ulna subcutaneous border extension.
    • soft tissues
      • identify radial nerve 
        • radial nerve crosses lateral intermuscular septum 14 cm proximal to the lateral epicondyle
        • ulnar nerve identified proximally
    • instrumentation
      • type 1 peri-articular olecranon fractures
        •  extensor mechanism disruption 
          • variation of tension band technique recommended
            • K-wires should be placed dorsal to implant to allow for engagement with the cement mantel followed by figure-of-8 technique
        • extensor mechanism intact and well-fixed stem
          • a simple excision of the fragment be performed
      • type II1 humerus fractures without component loosening
        • use allograft struts with cerclage cables
        • can use both anterior and posterior allograft struts if necessary 
        • fixation along the humeral implant is achieved using unicortical screws and cerclage cables
      • type III ulna fractures without component loosening
        • standard ORIF with plate fixation
    • complications
      • hardware prominence causing soft tissue and nerve irritation
  • Single stage revision TEA, +/- ORIF and allograft 
    • approach
      • as above 
    • bone work
      • removal of all loose implants and loose cement
    • instrumentation
      • canal must be prepared for an implant with a longer stem that will extend 2 cortical widths beyond a fracture (if present)
        • cementation preferred
          • important to cement revision stem before struts are placed because cement extravasation out of medullary canal may sit deep to allograft strut and prevent allograft incorporation or even cause nerve irritation. 
        • bone strut allograft
          • for humeral-sided fractures
            • a longer posterior and shorter anterior strut are preferred (to prevent impingement with elbow flexion)
          • for ulnar-sided fractures
            • dorsal allograft strut placed laterally under anconeus or medially under FCU to prevent subcutaneous prominence
        • plate and screw fixation
    • implants
      • long-stem implants should be used in all cases
  • Component explantation and 2-stage revision TEA
    • infection
      • approach 
        • posterior triceps-sparring approach recommended
      • soft tissue
        • if ulnar nerve has been previously transposed and patient has ulnar nerve symptoms, consider revising transposition or perform submuscular transposition
      • component explantation
        • removal of humeral prosthesis
          • Using burr and flexible osteotomes to remove cement circumferentially around the humerus. 
          • Loose components and those with precarious fixation may be removed with a slap-hammer extractor
            • If humeral component cannot be safely removed, a posterior humeral cortical split with use of saw and osteotomes can be used 
        • removal of ulnar prosthesis
          • In cases of well-fixed ulnar components and firmly retained cement, an extended olecranon osteotomy provides good exposure to the implant and cement 
            • should be repaired with cables followed reimplantation
            • should attempt to remove all cement
            • can use flexible reamers to further debride canal
      • antibiotic spacer
        • antibiotic spacers or beads are placed into both humeral and ulnar medullary canals
        • discs of cement placed in locations around articulation
          • avoid cement placement in subcutaneous tissue
      • static external fixator can stabilize joint while spacer in place
      • intravenous antibiotics
        • at least 6 weeks of intravenous culture specific antibiotics recommended prior to attempt at reimplantation
      • reimplantation
        • once inflammatory markers have normalized, can proceed with long-stem reimplantation
          • antibiotic cementation recommended 
    • periprosthetic fractures
      • may be performed in 2 stages: 
        • stage I - address fracture union with iliac crest bone graft and plate fixation.
        • stage II (after fracture union) - revise implants with longer stem and impaction graft 
  • Resection arthroplasty
    • approach
      • use prior surgical approach, specially if posterior midline
    • soft tissues 
      • care to keep thick subcutaneous soft tissue flaps to allow for skin closure
      • delicate and careful exposure of the ulnar and radial nerves should be performed, which may be located in the most unpredictable locations
    • bony work
      • proceed with explantation as above with careful removal of all cement
    • stabilization
      • In the absence of sufficient bone stability, the ulna and humerus may be stabilized with heavy sutures or wires through bone
Complications
  • Persistent deep infection
    • incidence
      • ~10% of patients following 2-stage revision, ~30% following single stage revision
    • risk factors
      • polymicrobial infections
      • rheumatoid patients on steroids
      • extensive bone loss
    • treatment 
      • resection arthroplasty
  • Ulnar nerve palsy
    • risk factors
      • cement extravasation from medullary canal
      • not visualization nerve during any revision surgery
  • Radial nerve palsy
    • risk factors
      • cement extravasation from medullary canal
      • impingement with long plates used for fracture fixation
  • Symptomatic hardware
    • risk factors
      • ORIF of periprosthetic ulna fractures
    • treatment
      • removal of hardware after fracture union
 

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(OBQ11.261) What is the preferred treatment for a propionibacterium acnes infection that has been symptomatic for 6 months after total elbow arthroplasty with well-fixed components, good bone stock, and a healthy patient? Review Topic | Tested Concept

QID: 3684
1

Non-operative treatment with IV antibiotics for 6 weeks

9%

(276/3201)

2

Arthroscopic irrigation and debridement

2%

(62/3201)

3

Open irrigation and debridement with poly exchange

13%

(426/3201)

4

Single stage revision arthroplasty

5%

(146/3201)

5

Two stage revision arthroplasty

71%

(2268/3201)

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