Revision Total Elbow Arthroplasty in the Presence of Bone Deficiency

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Chapter 45 Revision Total Elbow Arthroplasty in the Presence of Bone Deficiency

David Stanley

Introduction

Revision total elbow arthroplasty in the presence of bone deficiency is a challenging problem not only because of the osseous difficulties associated with reconstruction, but also because the surrounding soft tissues are frequently of poor quality and the neurovascular structures difficult to identify. In addition if there has been a relatively early failure of the primary arthroplasty the surgeon must consider the possibility of an underlying low-grade infection. Therefore before embarking on reconstruction it is important to carefully evaluate the severity of bone loss and to appropriately assess the patient for evidence of an underlying infection.

Background/aetiology

Bone loss at the elbow is most commonly seen in patients with rheumatoid arthritis, but may also result from severe open comminuted fractures of the distal humerus or proximal ulna. In patients who have previously undergone total elbow arthroplasties bone loss is either the result of progressive loosening of the implant or secondary to several revision procedures.

Assessment of the amount and type (cortical, intramedullary or both) of bone loss is important as this will dictate the type of reconstruction that is required. To assist with this assessment I have evolved a simple classification that reflects both increasing severe bone loss and increasingly demanding surgical reconstruction. In this classification, bone loss is divided into three types:

• Type 1 – Minimal bone loss
• Type 2 – Intramedullary bone loss
• Type 3 – Structural cortical bone loss

An alternative classification1 which is also helpful divides bone deficiency into: (1) deficient humeral or ulnar bone length; (2) compromised bone quality with ballooning of an intact cortex; and (3) periprosthetic fractures.

Presentation, investigations and treatment options

Presentation

The majority of patients requiring this type of revision surgery are elderly, have frequently undergone previous revision procedures and have comorbidities, particularly inflammatory arthritis. They typically present with increasing elbow pain and will often also complain of instability. The instability may result in difficulty controlling the forearm when the upper limb is being used but in severe cases will present as a flail elbow. The patient may at the time of presentation already be using a sling to support the arm. In addition if the elbow has been infected the patient may also complain of current or previous episodes of discharge from the joint.

Clinical examination must involve a full medical assessment in order to identify coexistent comorbidities together with a careful examination of the elbow. The elbow should be inspected for scars and sinuses and should be palpated for areas of tenderness and joint swelling. It is also important to try to identify the course of the ulnar nerve, as this may have been transposed at an earlier operation. Any evidence of sensory or motor ulnar nerve dysfunction should also be noted. The active and passive range of movement must be recorded and note made of any instability.

Clinical Pearl 45.1

It is important to perform a detailed clinical assessment of patients presenting with bone loss secondary to a failed total elbow arthroplasty because most patients are elderly and often have multiple comorbidities.

Investigations

Plain anteroposterior and lateral radiographs of the elbow are essential. These must include all of the prosthesis and must also show the extent of the cement in the proximal humerus and distal ulna. Routine screening blood tests – haemoglobin and full blood count, erythrocyte sedimentation rate, C-reactive protein, urea and electrolytes, and liver function tests – should also be performed. In combination with these investigations if there is any suggestion of previous or current joint infection it is my practice to perform a joint aspiration with the aspirate being sent for microscopy, culture and sensitivity. This investigation is undertaken in the radiology department under fluoroscopy control in order to be certain that a representative sample is obtained from the joint.

Treatments options

The aim of treatment is to intervene at an appropriately early stage so as to minimize bone loss and restore function. The options for achieving this are dependent on the severity of the bone loss and range from revision using a non-customized prosthesis for minimal bone loss, impaction bone grafting, customized prostheses for more extensive defects to autograft and allograft.

Although a one-stage revision is the preferred option for both the patient and the surgeon, this should not be undertaken when there is evidence of previous infection, a positive joint aspiration or if there is clinical suspicion of infection at the time of surgery. In these circumstances a two-stage revision should be performed. The first stage involves removal of the implant, all of the cement and the taking of multiple tissue samples for culture. In addition, once the debridement has been completed antibiotic beads are inserted into the joint cavity. These are made at the time of the first-stage procedure using gentamicin impregnated cement to which additional antibiotics are added. If a joint aspirate has been performed and an organism identified, the appropriate antibiotic to which that organism is sensitive is mixed with the gentamicin cement at the time the beads are made. If no organisms have been identified but there has been a previous infection or infection is suspected at the time of the revision 1 g of gentamicin together with 1 g of vancomycin are added to one mix of Palacos cement in order to produce high concentration wide-spectrum local cover. Postoperatively the arm is supported in a back slab until clinically and on serial blood tests (white cell count, erythrocyte sedimentation rate and C-reactive protein) the infection appears eradicated. Usually this will take at least 3 months but sometimes up to 12 months before I am confident that there is no residual infection. Occasionally if clinical or biochemical assessment suggests persisting infection, I will advise a repeat first-stage revision. When the infection is controlled the second stage procedure is performed with removal of the antibiotic beads and reconstruction of the joint.

Clinical Pearl 45.2

Although a one-stage revision is the preferred option for both the surgeon and the patient, this should not be undertaken if there is any evidence to suggest the presence of infection.

Summary Box 45.1 Treatment options in the presence of bone deficiency

Minimal bone loss

• Revision with a non-customized prosthesis

Advanced bone loss

• Impaction bone grafting
• Customized prosthesis
• Autograft
• Allograft

Surgical techniques and rehabilitation

Although all revisions undertaken in the presence of bone deficiency will present the surgeon with individual challenges, certain principles can be applied which will assist with the surgical procedure.

Patient position

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The Management of Delayed and Non-unions of the Distal Humerus Complications of Supracondylar Fractures and Their Management Surgical Anatomy of the Elbow Open Debridement and Interposition Neoplasms Around the Elbow Treatment by Open Surgical Techniques