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%) substantially higher than arthroplasty of other joints most common pathogen is s.aureas (~40%) followed by s.epidermidus (30-35%) worse outcomes with s.epidermidus risk factors for TEA infection higher prevalence in patients with rheumatoid arthritis on steroids hypothyroidism diabetes decreased thickness of soft tissue envelope prior elbow infection prior elbow surgery psychiatric illness periprosthetic fracture (5%) intra-operative can occur during bone preparation, reaming and implantation post-operative non-compliance with activities ground-level falls aseptic loosening (15%) higher rates associated with cementation and highly constrained systems can result from anterior impingement of coronoid being driven into anterior humeral flange during maximal elbow flexion instability commonly due to unconstrained TEA systems component failure (15%) most commonly due to bushing wear most common in younger patients or those with significant pre-existing deformity 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 pain at night or rest is a red flag for infection swelling stiffness decrease motion after a period of normal motion progressive loss of motion without identifiable cause is red flag for infection Physical exam inspection erythema/sinus tract in the setting of infection diffuse tenderness elbow swelling deformity in cases of significant bushing wear motion painful and limited range of motion crepitus/squeaking during motion Imaging Radiographs recommended views AP and lateral of humerus, elbow, and forearm findings periprosthetic component loosening early unexplained loosening concerning for infection periprosthetic humeral or ulnar fractures polyethylene bushing wear angle of intersection between the ulnar implant in relation to the humeral implant is measured mild-moderate bushing wear is considered when the angle > 10 degrees 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 negative cultures more common in chronic infections (~15%) compared to acute infections (3%) Treatment Nonoperative immobilization, functional elbow brace indications type I humeral condylar or olecranon fractures with stable prosthesis type III humeral fractures with stable implants patients who are not candidates for surgery (medical frailty, noncompliance, frequent falls) length length of immobilization depends on location of fracture (2-4 weeks) type transition to sarmiento (for Type III humerus fractures) or functional elbow brace (for Type 1 fractures) Operative irrigation and debridement, bushing exchange, component retention indications crepitus, squeaking +/- elbow pain with range of motion with stable implants and no evidence of infection (significant bushing wear) acute peri-prosthetic joint infection (presenting < 90 days from surgery) outcomes in appropriate candidates without signs of infection, 75% result in good results at 5 year followup following isolated bushing exchange in cases of acute infection, I&D and component retention is 63% effective at eradicating acute infections only 31% effective in management of chronic infections open reduction and internal fixation, component retention, +/- fracture excision, +/- strut allograft indications type I peri-articular olecranon fractures type II1 fractures type III fractures of the ulna outcomes 80-90% patients have no complications following isolated ORIF or excision for selected fractures single stage revision TEA, +/- ORIF and allograft indications type II2 periprosthetic humeral shaft or ulna fractures aseptic loosening outcomes only 66% affective for errdicating chronic TEA infection component explantation and 2-stage revision TEA indications Mayo II2 infected periprosthetic TEA outcomes success rate of eradicating chronic infection is 90% with 2-stage revision TEA (compared to 66% for single-stage) resection arthroplasty indications salvage procedure for treatment resistant PJI in patients who are unable to go multiple surgical procedures, have severe bone loss, and severely compromised soft tissue envelope Mayo II3 periprosthetic fractures not amendable for reconstruction outcomes 71% effective in completely eradication infection leads to the lowest functional scores (based on Mayo Elbow Performance score 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 if nerve is not symptomatic, it can be identified proximally and protected throughout rest of case 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 posterior paratricipital muscle sparing approach for ulna fractures posterior approach to elbow with ulna subcutaneous border extension. soft tissues identify radial nerve radial nerve crosses lateral intermuscular septum 14 cm proximal to the lateral epicondyle ulnar nerve identified proximally instrumentation type 1 peri-articular olecranon fractures extensor mechanism disruption variation of tension band technique recommended K-wires should be placed dorsal to implant to allow for engagement with the cement mantel followed by figure-of-8 technique extensor mechanism intact and well-fixed stem a simple excision of the fragment be performed type II1 humerus fractures without component loosening use allograft struts with cerclage cables can use both anterior and posterior allograft struts if necessary fixation along the humeral implant is achieved using unicortical screws and cerclage cables type III ulna fractures without component loosening standard ORIF with plate fixation 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) cementation preferred important to cement revision stem before struts are placed because cement extravasation out of medullary canal may sit deep to allograft strut and prevent allograft incorporation or even cause nerve irritation. bone strut allograft for humeral-sided fractures a longer posterior and shorter anterior strut are preferred (to prevent impingement with elbow flexion) for ulnar-sided fractures dorsal allograft strut placed laterally under anconeus or medially under FCU to prevent subcutaneous prominence plate and screw fixation implants long-stem implants should be used in all cases Component explantation and 2-stage revision TEA infection approach posterior triceps-sparring approach recommended soft tissue if ulnar nerve has been previously transposed and patient has ulnar nerve symptoms, consider revising transposition or perform submuscular transposition component explantation removal of humeral prosthesis Using burr and flexible osteotomes to remove cement circumferentially around the humerus. Loose components and those with precarious fixation may be removed with a slap-hammer extractor If humeral component cannot be safely removed, a posterior humeral cortical split with use of saw and osteotomes can be used removal of ulnar prosthesis In cases of well-fixed ulnar components and firmly retained cement, an extended olecranon osteotomy provides good exposure to the implant and cement should be repaired with cables followed reimplantation should attempt to remove all cement can use flexible reamers to further debride canal antibiotic spacer antibiotic spacers or beads are placed into both humeral and ulnar medullary canals discs of cement placed in locations around articulation avoid cement placement in subcutaneous tissue static external fixator can stabilize joint while spacer in place intravenous antibiotics at least 6 weeks of intravenous culture specific antibiotics recommended prior to attempt at reimplantation reimplantation once inflammatory markers have normalized, can proceed with long-stem reimplantation antibiotic cementation recommended periprosthetic fractures may be performed in 2 stages: stage I - address fracture union with iliac crest bone graft and plate fixation. stage II (after fracture union) - revise implants with longer stem and impaction graft 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