Summary Revision Total Elbow Arthroplasty is most commonly performed due to aseptic loosening, periprosthetic infection, or periprosthetic fracture with loose implants. Diagnosis is made with radiographs in the setting of periprosthetic fracture or implant loosening. Inflammatory markers and elbow aspiration can be helpful in diagnosis of periprosthetic infection. The type of revision depends on etiology of failure, patient age and patient comorbidities. 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) Etiology Pathophysiology 5 modes of TEA failure requiring revision infection (initially ~8% but since advent of DMARDs, rates have dropped to ~3%) login to view 11 more bullets periprosthetic fracture (5%) login to view 5 more bullets aseptic loosening (15%) login to view 2 more bullets instability login to view 1 more bullet component failure (15%) login to view 2 more bullets Classification Mayo (O'Driscoll & Morrey) Classification of Periprosthetic fracture 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 login to view 1 more bullet swelling stiffness decrease motion after a period of normal motion login to view 1 more bullet Physical exam inspection erythema/sinus tract in the setting of infection diffuse tenderness elbow swelling deformity login to view 1 more bullet motion painful and limited range of motion login to view 1 more bullet Imaging Radiographs recommended views AP and lateral of humerus, elbow, and forearm findings periprosthetic component loosening login to view 1 more bullet periprosthetic humeral or ulnar fractures polyethylene bushing wear login to view 2 more bullets 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 infection 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 login to view 1 more bullet Treatment Nonoperative immobilization, functional elbow brace indications login to view 3 more bullets length login to view 1 more bullet type login to view 1 more bullet Operative irrigation and debridement, bushing exchange, component retention indications login to view 2 more bullets outcomes login to view 3 more bullets open reduction and internal fixation, component retention, +/- fracture excision, +/- strut allograft indications login to view 3 more bullets outcomes login to view 1 more bullet single stage revision TEA, +/- ORIF and allograft indications login to view 2 more bullets outcomes login to view 1 more bullet component explantation and 2-stage revision TEA indications login to view 2 more bullets outcomes login to view 1 more bullet resection arthroplasty indications login to view 2 more bullets outcomes login to view 2 more bullets 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 login to view 1 more bullet 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 login to view 1 more bullet for ulna fractures login to view 1 more bullet soft tissues identify radial nerve login to view 2 more bullets instrumentation type 1 peri-articular olecranon fractures login to view 5 more bullets type II1 humerus fractures without component loosening login to view 3 more bullets type III ulna fractures without component loosening login to view 1 more bullet 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) login to view 8 more bullets implants long-stem implants should be used in all cases Component explantation and 2-stage revision TEA infection approach login to view 1 more bullet soft tissue login to view 1 more bullet component explantation login to view 9 more bullets antibiotic spacer login to view 3 more bullets static external fixator can stabilize joint while spacer in place intravenous antibiotics login to view 1 more bullet reimplantation login to view 2 more bullets periprosthetic fractures may be performed in 2 stages: login to view 2 more bullets 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 Staphylococcus epidermidis 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 Prognosis Prognostic variable depends on etiology of TEA failure, medical co-morbidities and remaining ulna and humeral bone stock