Revision Total Elbow Arthroplasty Research Articles

Impaction Grafting in Revision Total Elbow Arthroplasty for Aseptic Loosening and Bone Loss: Surgical Technique

Impaction Grafting in Revision Total Elbow Arthroplasty for Aseptic Loosening and Bone Loss: Surgical Technique

Impaction Grafting in Revision Total Elbow Arthroplasty Due to Aseptic Loosening and Bone Loss

With the increase in the number of total elbow arthroplasties being performed, there has been a parallel increase in revision surgery. There is limited information about the outcome of impaction grafting following failed elbow arthroplasty. We retrospectively analyzed sixteen cases of revision arthroplasty performed following aseptic loosening of a semiconstrained total elbow replacement. There were three men and thirteen women with a mean age of 58.4 years (range, twenty-eight to seventy-five years). Fourteen elbows had loosening of both the humeral and the ulnar component, and two elbows had only humeral loosening. Two elbows had perforation of the humeral cortex by the humeral component, and one had perforation of the ulnar cortex. Grade-II bone loss as described by King et al. was found in three elbows; grade III, in six elbows; and grade IV, in seven elbows. The impaction grafting was performed with only allograft in thirteen elbows, and it was done with allograft as well as autograft from the iliac crest in the other three elbows. The mean duration of follow-up was 7.4 years (range, 4.1 to 11.2 years). The mean Mayo Elbow Performance Score (MEPS) for pain significantly improved from 15.0 points preoperatively to 32.8 points at the time of latest follow-up (p = 0.003). The mean arc of flexion also significantly increased, from 60.3° to 115.6° (p < 0.01). Stability according to the MEPS significantly increased from a mean of 2.2 points to a mean of 9.4 points (p = 0.001). The mean total MEPS improved from 41.0 points to 82.8 points (p = 0.001). The result was excellent for four elbows, good for eleven, and fair for one. Follow-up radiographs demonstrated fifteen cases with grade-I resorption of the bone graft and one case with grade-II resorption. A type-I radiolucent line was observed in twelve of the elbows; type II, in three; and type IV, in one. Additional surgery was required in two cases. Impaction grafting is an effective technique when revision total elbow arthroplasty is used for the treatment of aseptic loosening with bone loss. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Allograft-Prosthetic Composite Reconstruction for Massive Bone Loss Including Catastrophic Failure in Total Elbow Arthroplasty

Revision total elbow arthroplasty with an allograft-prosthetic composite is a difficult salvage procedure due to massive bone loss and a compromised soft-tissue envelope. High failure rates in prior studies of patients treated with allograft-prosthetic composites and an increased burden of revision total elbow arthroplasties necessitate optimized reconstructive techniques to improve incorporation of allograft-prosthetic composites. The goal of this report is to describe novel techniques for, and outcomes of, reconstructions done with an allograft-prosthetic composite. From 2003 through 2008, twenty-five patients underwent revision total elbow arthroplasty with an allograft-prosthetic composite in the humerus (six), ulna (eighteen), or both (one). Indications included aseptic implant loosening with a fracture or cortical breach (eleven), aseptic implant loosening without fracture (three), infection (seven), failed implants (one), bone loss after hemiarthroplasty (one), nonunion (one), and resection arthroplasty (one). Three reconstructive strategies were used: intussusception of the allograft-prosthesis-composite (Type I), strut-like coaptation (Type II), and side-to-side contact between the cortices of the allograft-prosthetic composite and the host bone (Type III). The outcomes that were examined included the Mayo Elbow Performance Score (MEPS), radiographic union, and overall revision and complication rates. The mean MEPS improved from 30 points preoperatively to 84 points at the time of follow-up. Ninety-two percent of the allograft-prosthetic composites incorporated. There were eight major and four minor complications in nine patients, leading to nine reoperations in six patients. Complications included infection (three), fracture (three), nonunion (one), malunion (one), skin necrosis (one), triceps insufficiency/weakness (two), and ulnar nerve paresthesia (one). Four of the twenty-five patients had definitive resection arthroplasty, one had osteosynthesis, and one had a successful revision, so twenty-one (84%) of the twenty-five had a functional elbow. Five of seven infected joints were salvaged with staged allograft-prosthesis-composite procedures. Larger graft-host contact areas in the three types of allograft-prosthetic composites provided good functional outcomes and a high rate of union compared with prior experience and resection arthroplasty. Allograft-prosthetic composites can be a safe, reliable option with an acceptable complication rate for revision total elbow arthroplasty.

The Posterior Iliac Crest Outperforms the Anterior Iliac Crest When Obtaining Mesenchymal Stem Cells from Bone Marrow

The clinical application of freshly isolated connective-tissue progenitors, as well as the potential preparation of culture-expanded mesenchymal stem cell populations for therapeutic applications, will benefit from clinical methods that maximize the yield of the starting population. We compared the number of cells, concentration, and prevalence of colony-founding connective-tissue progenitors from the anterior and posterior iliac crest. In addition, we compared the expansion kinetics and multilineage differentiation potential of their culture-expanded progeny when processed to form mesenchymal stem cells. Marrow aspirate was collected from both the anterior and posterior iliac crest of twenty-two patients. The concentration and prevalence of colony-founding connective-tissue progenitors were estimated with use of a colony formation assay. The expansion kinetics and multilineage differentiation potential of the culture-expanded mesenchymal stem cell populations derived from these starting samples were compared. The yield of colony-founding connective-tissue progenitors was 1.6 times greater in the posterior compared with the anterior iliac crest. No differences were found with respect to the viability, phenotype, expansion kinetics, or multilineage differentiation potential of mesenchymal stem cell populations derived from these two sites. The concentration and yield of colony-founding connective-tissue progenitors were greater when aspirate was obtained from the posterior compared with the anterior iliac crest, whereas the biological potential of the cells derived from these sites appeared comparable. The harvesting of bone marrow from the posterior iliac crest appears to be preferred, as it provided a modestly higher concentration of colony-founding connective-tissue progenitors than comparable aspirate from the anterior iliac crest.

Characterization of wear debris in total elbow arthroplasty

The purpose of this study was to evaluate wear debris in periprosthetic tissues at the time of revision total elbow arthroplasty. Polyethylene, metallic, and bone cement debris were characterized, and the tissue response was quantified. Capsular and medullary tissue samples were collected during revision surgery. Polyethylene debris was characterized by scanning electron microscopy after tissue digestion. The concentrations of metal and cement debris were quantified by inductively coupled plasma mass spectrometry. Tissue response was graded with a semiquantitative histologic method. Polyethylene particle size varied from the submicron range to over 100 μm. The mean diameter ranged from 0.6 μm to about 1 μm. Particles in the synovial tissues were larger and less abundant than those in tissues from the medullary canal. Cement, titanium alloy, and low levels of cobalt-chrome debris were also present, with cement predominating over metal debris. Histiocyte response was associated with small polyethylene particles (0.5-2 μm), and giant cells were associated with large polyethylene particles (>2 μm). Histiocyte scores positively correlated with the polyethylene particle number and the presence of metal. We have shown that periprosthetic tissues of total elbow patients who have undergone revision for loosening and osteolysis contain polyethylene, cement, and metal debris. Although the polyethylene particles were of a size and shape that have been previously shown to result in activation of phagocytic cells, osteolysis after total elbow arthroplasty is a multimodal process. Because of the presence of multiple wear particle sources, a cause-and-effect relationship between polyethylene debris and osteolysis cannot be established with certainty.

Activities after total elbow arthroplasty

Knowledge of patient activities after total elbow arthroplasty may help delineate the true functional gains obtained after replacement. Experience suggests that some patients may perform activities excessively demanding on elbow implants, but compliance with activity restrictions recommended after elbow arthroplasty is largely unknown. All patients who underwent a primary or revision total elbow arthroplasty at a single institution from 2005 to 2007 were surveyed regarding their activity level. The University of California, Los Angeles (UCLA) activity score and Mayo Elbow Performance Score were assessed. Patients were also questioned about whether they recalled which activities were not recommended by their surgeon. One hundred thirteen completed surveys were analyzed. There were 29 men and 84 women with a mean age of 65 years. Of the patients, 64 had primary and 49 had revision operations. The mean Mayo Elbow Performance Score was 77 points (range, 15-100 points). The mean University of California, Los Angeles activity score was 5 points (range, 1-10 points). Moderate-demand activities were performed by 94% of patients, and high-demand activities were performed by 40% of patients. Male gender and a diagnosis of fracture/nonunion was associated with increased performance of high-demand activities (P < .05). Eighty percent of patients remembered receiving postoperative restrictions, and of these patients, 83% interpreted that they were compliant with their restrictions. Ninety-four percent of patients engaged in moderate-demand activities after total elbow arthroplasty. Forty percent engaged in high-demand activities. Factors correlated with more demanding activities included male gender and diagnosis of fracture/nonunion. The vast majority of patients remembered receiving postoperative restrictions.

Revision total elbow arthroplasty with the linked Coonrad-Morrey total elbow arthroplasty: a retrospective study of twenty procedures

In this retrospective study we evaluated the short- to medium-term results after 20 Coonrad-Morrey revision total elbow arthroplasties (TEAs). We included a consecutive series of revision TEAs performed at our institution from 2004 to 2010. At a mean follow-up of 4.4years, patients were evaluated using the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES) and standard radiographs. The mean age at revision TEA was 65.8years. The median time of implant survival for primary prosthesis was 9.5years. The mean post-operative MEPS was 79. The mean OES was 58, 66 and 53 for function, pain and social-psychological dimensions, respectively. At follow-up the range of motion had improved significantly. There were two cases of radiolucent lines and two cases of minor bushing wear; however, none of the implants were clinically loose. In one case deep infection led to a further revision. Two patients had post-operative ulnar nerve paraesthesia. Results after revision TEA using the Coonrad-Morrey prosthesis are acceptable with a low short- to midterm failure rate. Revision improves range of motion and provides pain relief. One case of deep infection with recurrent revision is of concern. The treatment can be used as an option for failed TEA.

A Case of Bilateral Revision Total Elbow Arthroplasty after Simulation Using Stereolithographic Models

A Case of Bilateral Revision Total Elbow Arthroplasty after Simulation Using Stereolithographic Models

Interprosthetic humeral fracture revision using a tibial allograft total elbow prosthetic composite in a patient with hemophilia A : a case report

IntroductionInterprosthetic fractures of the humerus are rare. Revisions of total elbow arthroplasty components in these cases are difficult. We report the first case of a patient with hemophilia who underwent a revision with a tibial allograft prosthetic composite without the need for hardware augmentation.Case presentationA 43-year-old Caucasian man with a history of hemophilia and transfusion-related human immunodeficiency virus and hepatitis B and C presented with an interprosthetic fracture of his humerus after months of pain between his total elbow and total shoulder arthroplasties. Because of the poor remaining bone stock available in his distal humerus, a revision using a barrel-staved tibial allograft prosthetic composite was performed. Our patients’ factor VIII level was optimized before the operation and he suffered no major long-term complications at 28 months. His only complication was an incomplete radial nerve palsy that ultimately recovered and left him with some numbness on the dorsum of his hand.ConclusionCareful use of an allograft prosthetic composite is a very reasonable option when a patient experiences an interprosthetic fracture. We have successfully performed revision total elbow arthroplasty for a patient with hemophilia with an interprosthetic fracture using a tibial allograft and no additional fixation, which resulted in his return to full activities of daily living, minimal pain and full incorporation of the allograft to host bone.

Use of a femoral impaction grafting system in revision total elbow arthroplasty

Use of a femoral impaction grafting system in revision total elbow arthroplasty

The “anconeus slide”: rotation flap for management of posterior wound complications about the elbow

Wound dehiscence at the tip of the olecranon is not an uncommon complication associated with surgical approaches to the elbow that involve a posterior skin incision. Various flaps have been described in the treatment of such soft tissue defects, but have associated morbidity. The "anconeus slide" rotation flap has low morbidity and is technically simple. In this study, we review the surgical technique and describe our experience with the anconeus rotation flap in 20 consecutive patients. The records of 20 patients who underwent an anconeus rotation flap by a single surgeon, from September 2006 to March 2010 were reviewed. The procedure was performed in the setting of total elbow arthroplasty (TEA) in 12 patients, revision total elbow arthroplasty in 3 patients, wound complications in 4patients, and for an acute open distal humerus fracture in 1 patient. Patients were evaluated postoperatively for wound healing, pain, and postoperative Mayo Elbow Performance Scores (MEPS). All 20 patients healed their surgical wounds completely. Postoperative MEPS scores averaged 79.3 (range, 50-100). The anconeus rotational flap is a technically simple, reliable, and safe option for treatment of posterior wound complications about the elbow, and in the setting of primary and revision TEA when wound healing is a clinical concern. We recommend its use in patients who have either compromised posterior soft tissue coverage, triceps insufficiency, or factors associated with the potential for compromised wound healing.

Custom triflange outrigger ulnar component in revision total elbow arthroplasty

This study describes the rationale for, and tests the hypothesis that, a custom outrigger triflange ulnar component for revision total elbow arthroplasty would decrease the contact stresses at thebushings and overcome excessive bushing wear in active patients who have bone and ligamentous deficiency. Five consecutive revisions for failed Coonrad-Morrey total elbow arthroplasties were performed with the custom outrigger triflange ulnar component for patients with accelerated bushing wear, ulnar component loosening, and deficient humeral condyles. The mean age at the time of surgery was 48 years (range, 32-64 years). Follow-up averaged 81 months (range, 65-124 months). The average number of previous operations was 2.4 (range, 2-3). The Mayo Elbow Performance Score improved from 40 (range, 15-65) preoperatively to 91 (range, 80-100) at the latest follow-up. There were two excellent and three good results. There was no radiographic or clinical evidence of bushing wear at 6.8 years of follow-up (range, 5.5-10.3 years). One patient required further revision of the humeral component due to mechanical loosening, which had not been revised at the time of the index surgery. A custom outrigger triflange ulnar component is an effective alternative for revising loose Coonrad-Morrey ulnar components in active patients with absent humeral epicondyles and accelerated bushing wear. It may be an alternative to revision with standard components until improved surgical designs addressing this problem become commercially available.

Revisionsendoprothetik des Ellenbogens

Total elbow arthroplasty (TEA) is gaining in popularity. An elbow prosthesis is nowadays no longer regarded as a salvage procedure for low demand patients but is increasingly used in younger, active patients with higher demands. In elderly patients TEA is more and more accepted as a primary treatment method for osteoporotic complex distal humerus fractures. Nevertheless, TEA is technically demanding and associated with a higher complication and revision rate compared to e.g. hip prostheses. Increasing implantation rates in a juvenescent population will lead to a considerable increase in revision rates. Most common causes are aseptic and septic loosening as well as implant failure and instability. Cemented semi-constrained prostheses are mostly used for revision elbow arthroplasty. This article deals with the causes of revision elbow arthroplasty and describes the operative technique of revision of total elbow arthroplasty.

Implications of revision total elbow arthroplasty on blood transfusion

We hypothesize that there is a greater rate of blood transfusions following revision total elbow arthroplasty (TEA) as compared with primary TEA, with lower preoperative hemoglobins and longer operative times being significant risk factors. The results of 193 operations (172 patients) between January 2000 and December 2004 were retrospectively reviewed. Excluded were patients with primary impairment of platelet or coagulation function or with chronic liver impairment. Univariate and chi(2) analyses were used to determine which risk factors were predictive of transfusion. The transfusion rate was 7.8% for revision arthroplasties and 1.0% after primary procedures (P < .02). Revision surgery (P < .02), longer operative times (P < .01), longer anesthesia times (P < .01), lower preoperative hemoglobin level (10.6+/-0.5 g/dL; P < .01), and lower body mass index (P=.04) significantly increased the risk of blood transfusion. The need for blood transfusion after revision elbow arthroplasty is statistically greater than that after primary procedures. Furthermore, revision surgery, increased operative and anesthesia times, lower preoperative hemoglobin level, and decreased body mass index increase the risk of requiring a transfusion. Patients undergoing revision surgeries with preoperative hemoglobin levels of less than 10 g/dL are especially at risk of transfusion, and the proper precautions should be enacted during the perioperative period.

X-ray study of revision total elbow arthroplasty with rheumatoid arthritis

X-ray study of revision total elbow arthroplasty with rheumatoid arthritis

A new technique for management of ulnar bone loss in revision total elbow arthroplasty using a tuberized tricortical iliac crest autograft: A case report

Total elbow arthroplasty has become a relatively common procedure for the treatment of the arthritic elbow.8 Because the number of primary total elbow replacements performed is likely to increase as the population ages, the incidence of technically demanding revision procedures is also expected to increase.16 These procedures often involve complex problems, such as major bone loss, which contribute to their complexity.

Semiconstrained Primary and Revision Total Elbow Arthroplasty with Use of the Coonrad-Morrey Prosthesis

Semiconstrained total elbow prostheses are used routinely by many surgeons to treat a variety of severe elbow disorders. Our objective was to review the results of primary and revision total elbow arthroplasty with use of the Coonrad-Morrey prosthesis. The selected use of this semiconstrained implant in patients with instability and poor bone stock was hypothesized to provide inferior results compared with those in the published reports. The results of sixty-seven semiconstrained total elbow arthroplasties that were performed in fifty-six patients between 1990 and 2003 were evaluated. Thirty-seven elbows had a primary arthroplasty and were followed for a mean of eighty-six months, and thirty elbows had a revision arthroplasty and were followed for a mean of sixty-eight months. Mayo elbow performance scores and radiographic analyses were used to assess the clinical results. In the primary arthroplasty group, the average flexion improved from 116 degrees to 135 degrees; average extension, from -40 degrees to -33 degrees; average pronation, from 60 degrees to 81 degrees; and average supination, from 60 degrees to 69 degrees. The improvements in flexion and pronation were significant (p<0.001 for both). Preoperatively, twenty-five (74%) of thirty-four elbows with data available had moderate or severe pain, whereas only four (11%) had pain postoperatively. The average postoperative Mayo score (and standard deviation) was 84+/-16. Eleven of the thirty-seven primary replacements failed, and the five-year survival rate was 72%. In the revision arthroplasty group, average flexion improved from 124 degrees to 131 degrees; average extension, from -32 degrees to -22 degrees; average pronation, from 66 degrees to 75 degrees; and average supination, from 64 degrees to 76 degrees; the improvement in supination was significant (p<0.05). Preoperatively, eighteen (64%) of the twenty-eight elbows with data available had moderate or severe pain, while only five (17%) had pain postoperatively. The average postoperative Mayo score was 85+/-16. Eleven of the thirty revision replacements failed, and the five-year survival rate was 64%. A Coonrad-Morrey semiconstrained total elbow arthroplasty provides excellent pain relief and good functional return in patients with severe destructive arthropathy. The higher prevalence of failure in this cohort compared with series reported elsewhere is likely due to adverse patient selection as this implant was reserved for more complex arthroplasties with severe bone loss and ligamentous laxity.

Semiconstrained Primary and Revision Total Elbow Arthroplasty with Use of the Coonrad-Morrey Prosthesis

Background: Semiconstrained total elbow prostheses are used routinely by many surgeons to treat a variety of severe elbow disorders. Our objective was to review the results of primary and revision total elbow arthroplasty with use of the Coonrad-Morrey prosthesis. The selected use of this semiconstrained implant in patients with instability and poor bone stock was hypothesized to provide inferior results compared with those in the published reports. Methods: The results of sixty-seven semiconstrained total elbow arthroplasties that were performed in fifty-six patients between 1990 and 2003 were evaluated. Thirty-seven elbows had a primary arthroplasty and were followed for a mean of eighty-six months, and thirty elbows had a revision arthroplasty and were followed for a mean of sixty-eight months. Mayo elbow performance scores and radiographic analyses were used to assess the clinical results. Results: In the primary arthroplasty group, the average flexion improved from 116° to 135°; average extension, from –40° to –33°; average pronation, from 60° to 81°; and average supination, from 60° to 69°. The improvements in flexion and pronation were significant (p < 0.001 for both). Preoperatively, twenty-five (74%) of thirty-four elbows with data available had moderate or severe pain, whereas only four (11%) had pain postoperatively. The average postoperative Mayo score (and standard deviation) was 84 ± 16. Eleven of the thirty-seven primary replacements failed, and the five-year survival rate was 72%. In the revision arthroplasty group, average flexion improved from 124° to 131°; average extension, from –32° to –22°; average pronation, from 66° to 75°; and average supination, from 64° to 76°; the improvement in supination was significant (p < 0.05). Preoperatively, eighteen (64%) of the twenty-eight elbows with data available had moderate or severe pain, while only five (17%) had pain postoperatively. The average postoperative Mayo score was 85 ± 16. Eleven of the thirty revision replacements failed, and the five-year survival rate was 64%. Conclusions: A Coonrad-Morrey semiconstrained total elbow arthroplasty provides excellent pain relief and good functional return in patients with severe destructive arthropathy. The higher prevalence of failure in this cohort compared with series reported elsewhere is likely due to adverse patient selection as this implant was reserved for more complex arthroplasties with severe bone loss and ligamentous laxity. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Prevalence of Pulmonary Embolism After Total Elbow Arthroplasty

Although numerous articles have addressed the risk of pulmonary embolism following total knee and total hip arthroplasty, we were unable to find comparable information for the risk following elbow arthroplasty. We therefore sought to determine the prevalence of pulmonary embolism after total elbow arthroplasty. We conducted a retrospective review of the medical records of consecutive patients who had undergone primary elbow arthroplasty (816 procedures) or revision total elbow arthroplasty (260 procedures) at our tertiary-care academic medical institution between June 1981 and June 2001. Our purpose was to identify all patients in whom a pulmonary embolism developed after the surgery. Three patients had a pulmonary embolism and one died as a result of the complication during the twenty-year study period. Because of a low index of suspicion, the presenting symptoms of the pulmonary embolus were originally attributed to other causes of respiratory distress in two of the three patients. These findings suggest that pulmonary embolism after total elbow arthroplasty is a rare but potentially fatal complication. Surgeons should consider this diagnosis when a patient exhibits respiratory distress after total elbow arthroplasty.

Total Elbow Prosthesis Loosening Caused by Ulnar Component Pistoning

Background: Linked semiconstrained total elbow prostheses have been used successfully but may be at higher risk for implant loosening than unlinked implants are. The purpose of the present report was to describe a previously unreported and potentially preventable cause of mechanical loosening of the ulnar component of a linked total elbow prosthesis. Methods: A series of ten patients who had painful pistoning of the polymethylmethacrylate-coated ulnar component of a Coonrad-Morrey linked total elbow prosthesis were evaluated clinically and radiographically. Results: All ten patients complained of elbow pain, and eight had a distinct sensation of the ulnar component moving within the ulna. Six patients either complained of squeaking within the elbow or could demonstrate squeaking on examination. Four patients had a complete radiolucent line around the ulnar component or the cement mantle, and six had an incomplete line around the ulnar component. Six patients had a radiolucent gap between the cement and the tip of the ulnar prosthesis. Two patients had proximal migration of the ulnar component within the cement mantle on lateral flexion radiographs. Three patients had anterior impingement, such as between the anterior flange of the humeral implant and a prominent coronoid process, on lateral flexion radiographs. At the time of revision arthroplasty, all ten patients were found to have a loose ulnar component, which was successfully revised with or without impaction grafting. At the time of the most recent follow-up, nine of the ten ulnar components were intact and stable. Three patients required an additional reoperation: one required triceps repair, one required revision of a loose humeral component, and one required a revision total elbow arthroplasty. Conclusions: Pistoning of the ulnar component in the cement mantle leading to failure by means of a pullout mechanism can occur in association with the Coonrad-Morrey total elbow prosthesis with a polymethylmethacrylate-precoated ulnar component. To prevent this problem following any total elbow arthroplasty, the surgeon should check for anterior impingement intraoperatively by ensuring that there is no contact between the anterior flange and a prominent coronoid process or the cement and that no distraction of the trial ulnar component from the ulna occurs with passive elbow flexion. This condition also can be avoided by ensuring that the ulnar component is not inserted too far distally. This mechanism of failure should be considered when future total elbow arthroplasty implants are designed. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.