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

Is systematic 1-stage exchange a valid attitude in chronic infection of total elbow arthroplasty?

INTRODUCTION

Surgical treatment for chronic infection of total elbow arthroplasty (TEA) generally involves 2-stage exchange. In the lower limb, 1-stage strategies are increasingly implemented, but few cases have been reported for the elbow. We present results in a preliminary series, with the aim of: (1) assessing control of infection in systematic 1-stage exchange for chronic TEA infection, (2) detailing clinical and radiological results, and (3) analyzing intra- and post-operative complications.

HYPOTHESIS

Systematic 1-stage exchange for chronic TEA prosthetic joint infection provides satisfactory control of infection.

MATERIAL AND METHODS

Seven non-selected patients were operated on by 1-stage exchange for chronic infection of TEA during the study period. Two died before the minimum 2 years' follow-up, from causes unrelated to the infection. Thus 5 patients (4 women, 1 man; mean age at surgery, 61 years [range: 48-69 years]) were included for analysis. At a minimum 2 years' follow-up, all underwent clinical examination and elbow X-ray. Infection was monomicrobial in 4 cases and polymicrobial in 1. Isolates comprised Staphylococcus aureus in 40% of cases (2/5), Staphylococcus epidermidis in 60% (3/5) and Staphylococcus Warneri in 20% (1/5). Three patients showed fistula. Three were under immunosuppression/immunomodulation treatment.

RESULTS

At a mean 40 months' follow-up (range: 24-60 months), 4 patients (80%) were free of infection and 1 showed signs of persistent infection. Mean range of flexion-extension was 81° (range: 60-95°) and pronation-supination 128° (range: 80-160°). Mean Mayo Elbow Performance Score was 75 points (range: 65-90). There were 2 intraoperative fractures and 1 neurologic deficit with partial regression.

CONCLUSION

One-stage exchange provided control of infection in 80% of cases, despite cutaneous fistulae or immunosuppression treatment. Clinical results and complications rate were similar to those reported for 2-stage exchange.

LEVEL OF EVIDENCE

IV; retrospective study without control group.

Revision total elbow arthroplasty failure rates: the impact of primary arthroplasty failure etiology on subsequent revisions

BACKGROUND

The number of primary total elbow arthroplasties (TEAs) performed is increasing annually, necessitating a rise in the number of revision procedures. No studies exist to illustrate reliable indications for revision arthroplasty. The purpose of this study was to determine the impact of the etiology of primary TEA failure on the failure rate of revision surgery.

METHODS

We retrospectively analyzed the patient charts of all revision TEAs performed at a single institution between 2006 and 2016. The primary outcome was revision failure, defined as the need for a second revision surgical procedure. Patients were organized into cohorts by etiology of primary implant failure. Failure rates, time to second revision, and average number of additional revisions were compared among cohorts.

RESULTS

A total of 46 patients with a mean age of 62.7 years and minimum 2-year follow-up were included. The etiologies of failure identified were infection (n = 20), aseptic loosening (n = 17), periprosthetic fracture (n = 6), and bushing wear (n = 3). All noninfectious etiologies were grouped into an additional cohort. Patients who underwent revision for infection demonstrated a significantly greater failure rate and greater number of additional revisions per patient than those with aseptic loosening, those with periprosthetic fracture, and the noninfectious group, as well as a shorter time to failure than the noninfectious group.

CONCLUSION

Patients in whom primary TEA fails because of infection are more likely to experience revision failure and require a greater number of subsequent operations than patients with other etiologies of primary TEA failure. These data question the efficacy of revision surgery in the treatment of infected TEAs.

A Clinical Comparison of Triceps-Sparing and Triceps-Detaching Approaches for Revision Total Elbow Arthroplasty

PURPOSE

Triceps-sparing (TS) approaches have been reported to provide improved triceps strength, better patient outcomes, and a lower incidence of complications in primary total elbow arthroplasty (TEA). It remains unclear whether the advantages of this approach are similar in the revision setting, especially in cases with prior triceps detachment. The purpose of this study was to compare triceps strength and clinical outcomes between TS and triceps-detaching (TD) approaches in revision TEA.

METHODS

All revision TEAs performed over a 17-year period with a minimum 1-year follow-up were retrospectively reviewed. Elbows with preoperative triceps insufficiency or subsequent component removal for infection were excluded. Patients were grouped according to the surgical approach performed at the last revision TEA. Outcome measures included triceps strength, range of motion, visual analog scale (VAS), Mayo Elbow Performance Score (MEPS), and Disabilities of the Arm, Shoulder, and Hand (DASH) scores.

RESULTS

Ten TS and 6 TD elbows were evaluated. Four elbows within the TS group had documented TD surgery prior to revision. Median follow-up was longer in the TD group (137 ± 75 months vs 53 ± 20 months). Functional strength and DASH scores were significantly better in the TS group. Arc of motion, VAS, and MEPS were similar between the TS and the TD groups.

CONCLUSIONS

The TS approach preserves greater postoperative functional triceps strength after revision TEA, regardless of the type of approach used previously.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Outcomes after revision total elbow arthroplasty: a systematic review

BACKGROUND

Although revision arthroplasty surgery is a frequently used treatment for failed total elbow arthroplasty (TEA), published results are conflicting. The aim of this systematic review was to provide an overview of the outcomes of revision TEA surgery.

METHODS

A systematic literature search was performed in major databases to find articles relating to outcomes after revision of TEA. Two reviewers independently screened the articles for inclusion, and a third reviewer screened them before final inclusion.

RESULTS

Twenty-one articles containing 532 cases were included. The mean age at revision was 61 years. The mean interval between primary and revision arthroplasty was 77 months, and the average follow-up period was 65 months. Different types of prostheses were included, with 69% of the revision prostheses having linked designs and 31% having unlinked designs. The visual analog scale score, Mayo Elbow Performance Score, Oxford Elbow Score, and range of motion improved significantly after revision surgery. Complications were reported in 232 of 532 cases (44%), leading to reoperations in 22%. After revision with linked prostheses, the Mayo Elbow Performance Score, range of flexion-extension, and pronation improved significantly more than with unlinked designs.

CONCLUSION

Improved functional outcomes can be expected after revision TEA, but the complication rate remains high. Revision TEA should still be considered a salvage procedure for failed TEA. Linked designs for revision TEA result in better outcomes than unlinked designs in the midterm follow-up.

Clinical and radiographic outcome of revision surgery of total elbow prosthesis: midterm results in 19 cases

BACKGROUND

The aim of this study is to report on the midterm outcomes and complications of revision surgery of total elbow arthroplasty.

METHODS

All patients who had undergone total elbow arthroplasty revision surgery between 2009 and 2014 with semiconstrained total elbow prostheses were prospectively enrolled in the study. Records were reviewed for demographic data; baseline measurements; and several follow-up assessments including the Mayo Elbow Performance Score (MEPS), visual analog scale (VAS) score for pain, Oxford Elbow Score, range of motion, satisfaction, and radiographs.

RESULTS

A total of 19 revision arthroplasties were included. At a mean follow-up of 57 months, there had been 1 rerevision and 2 removals. One patient was excluded from follow-up because of confounding comorbidity. At last follow-up, MEPS values and VAS pain scores both improved (P < .01). The rate of combined good and excellent results on the MEPS was 53%. The mean VAS scores for pain at rest and with activity were 2 and 4, respectively. Fair results for the Oxford Elbow Score were reported, with a mean score of 28 points. Range of motion improved to an average flexion-extension arc of 108° (P < .01), and the pronation-supination arc improved to an average of 123° (P < .01). All elbows were stable at last follow-up (P < .01). Radiographs showed nonprogressive osteolysis around the prosthesis in 3 cases (19%) and suspicion of loosening in 1 (6%). In 11 patients postoperative complications occurred. Of 15 patients, 13 (87%) were satisfied with the result of the revision procedure.

CONCLUSION

Revision of total elbow prostheses leads to satisfactory results, less pain, and better elbow function. This procedure is related to a relatively high complication rate.

Total elbow arthroplasty is moving forward: Review on past, present and future

The elbow joint is a complex joint, which, when impaired in function, leads to severe disability. In some cases however, an arthroplasty might be an appropriate treatment. In the past four decades, large steps have been taken to optimize this treatment in order to achieve better post-operative outcomes. To understand these progresses and to discover aspects for upcoming improvements, we present a review on the past developments, the present state of affairs and future developments which may improve patient care further.

Outcome after total elbow arthroplasty: a retrospective study of 167 procedures performed from 1981 to 2008

BACKGROUND

Total elbow arthroplasties (TEAs) are traditionally grouped into linked and unlinked design. The aim was to analyze the difference in clinical outcomes after TEA based on implant design and indication for surgery and to evaluate primary and revision TEAs.

METHODS

A total of 167 TEAs (126 primary and 41 revision TEAs) in 141 patients were evaluated with patient-reported outcome measure by the Oxford Elbow Score (OES) and clinically assessed with the Mayo Elbow Performance Score (MEPS), range of motion (ROM), and standard radiographs.

RESULTS

The mean follow-up was 10.5 years for primary and 7.5 years for revision TEAs. There was no difference in OES or MEPS between linked and unlinked primary TEAs. The OES score in the social-psychological domain was significantly lower in TEAs performed due to fracture (67) compared with rheumatoid arthritis (81; P = .025). ROM in extension-flexion was 116° for primary linked TEAs compared with 110° for primary unlinked TEAs (P = .02). Revision TEAs were associated with a poorer outcome in OES, MEPS, and ROM compared with primary TEAs. Radiographic signs of loosening were seen in 15 primary and 7 revision TEAs at follow-up.

CONCLUSIONS

We found no clinically significant differences in outcomes after linked or unlinked TEAs. Patients with TEAs due to fracture had poorer social-psychological results than rheumatoid arthritis patients. The results after revision surgery were significantly inferior compared with primary procedures. The OES contributes to the evaluations of the outcome after TEA surgery with a nuanced picture of the patient's perception.

Revisiting the 'bag of bones': functional outcome after the conservative management of a fracture of the distal humerus

The best method of managing a fracture of the distal humerus in a frail low-demand patient with osteoporotic bone remains controversial. Total elbow arthroplasty (TEA) has been recommended for patients in whom open reduction and internal fixation (ORIF) is not possible. Conservative methods of treatment, including the 'bag of bones' technique (acceptance of displacement of the bony fragments and early mobilisation), are now rarely considered as they are believed to give a poor functional result. We reviewed 40 elderly and low-demand patients (aged 50 to 93 years, 72% women) with a fracture of the distal humerus who had been treated conservatively at our hospital between March 2008 and December 2013, and assessed their short- and medium-term functional outcome. In the short-term, the mean Broberg and Morrey score improved from 42 points (poor; 23 to 80) at six weeks after injury to 67 points (fair; 40 to 88) by three months. In the medium-term, surviving patients (n = 20) had a mean Oxford elbow score of 30 points (7 to 48) at four years and a mean Disabilities of the Arm, Shoulder and Hand score of 38 points (0 to 75): 95% reported a functional range of elbow flexion. The cumulative rate of fracture union at one year was 53%. The mortality at five years approached 40%. Conservative management of a fracture of the distal humerus in a low-demand patient only gives a modest functional result, but avoids the substantial surgical risks associated with primary ORIF or TEA.

Primary total elbow arthroplasty in complex fractures of the distal humerus

AIM: To evaluate short- to medium term outcome of total elbow arthroplasty (TEA) in complex fractures of the distal humerus.

METHODS: A consecutive series of 24 complex distal humerus fractures operated with TEA in the period 2006-2012 was evaluated with the Mayo Elbow Performance score (MEPS), plain radiographs, complications and overall satisfaction. The indications for surgery were 1: AO type B3 or C3 or Sheffield type 3 fracture and age above 65 or 2: fracture and severe rheumatoid arthritis. Mean follow-up time was 21 mo.

RESULTS: Twenty patients were followed up. Four patients, of which 3 had died, were lost to follow up. According to the AO classification there were 17 C3, 1 B2 and 2 A2 fractures. Mean follow-up was 21 months (range 4-54). Mean MEPS was 94 (range 65-100). Mean flexion was 114 degrees (range 80-140). According to MEPS there were 15 excellent, 4 good and 1 fair result. Patient satisfaction: 8 excellent, 10 good, 2 fair and 1 poor. There were two revisions due to infection treated successfully with revision and three months of antibiotics. In two patients the locking split had loosened. One was referred to re-insertion and one chose yearly controls. Two patients had persistent dysaesthesia of their 5th finger, but were able to discriminate between sharp and blunt.

CONCLUSION: Our study suggests that TEA in complex fractures of the distal humerus in elderly patients can result in acceptable short- to medium term outcome.