Two-staged revision of the infected total elbow arthroplasty with an articulating spacer: a good option for an unsolved problem

Abstract

Background/PurposeInfection after total elbow arthroplasty (TEA) is a difficult problem for both patients and surgeons. When two-stage revision is required, a custom antibiotic laden articulating spacer fashioned using Ilizarov external fixation rods allows for a functional elbow prior to revision. The purpose of this review and case series is to investigate clinical and patient reported outcomes of the articulating spacer and investigate its effectiveness as bridge prosthesis and a long-term option prior to revision. MethodsA retrospective review between 2016 and 20 identified patients with an infected TEA treated with an articulating spacer. Patient age, surgical indication, spacer duration, and comorbidities were recorded. Outcome scores included Visual Analog Scale (VAS) for pain (1-10), Single Assessment Numerical Evaluation (SANE) (0-100%) of overall elbow function, and range of motion at the pre-spacer, three month, and most recent follow-up visit. Statistical analysis compared outcomes at each time period using an analysis of variance or Friedman's test followed by post-hoc analyses using paired t-tests or Sign tests. Minimal Detectable Change (MDC) was calculated for pain and SANE scores. ResultsEleven articulating spacers (9 patients) with 13 months mean spacer implantation were identified. Mean long-term spacer implantation (4 patients, 6 spacers) was 22 months (range 7-40). Median pain scores were significantly lower at three month and latest follow-up relative to preoperative assessment. Analysis of long term spacers revealed a significant decrease in pain scores from pre-op to 3 months. Analysis of SANE scores demonstrated three month and latest follow-up scores to be significantly improved from preoperative assessment. SANE scores for long-term spacers were significantly improved at three months and last follow-up. Range of motion analysis demonstrated no significant differences other than significantly increased pronation/supination at three months in long term spacers. Eight of 11 spacers met MDC for pain and 5/11 for SANE at three months. Three of 6 long-term spacers met MDC for SANE. Total implant cost is $158.32. ConclusionMost spacers are effective in clearing infection, but a custom articulating spacer importantly provides significant, early pain relief and improved patient reported function of the elbow. Improvements in range of motion are also achieved. An articulating spacer allows for an improved quality of life during the interim period prior to revision as well as a long-term option providing sustained improvement in function for those unwilling to undergo further surgery or with complex medical issues that preclude them from a definitive revision. Level of EvidenceLevel IV; Case Series