Restoring Functionality: Humeroradial Total Elbow Revision for Salvaging Total Elbow Arthroplasty Failure and Ulnar Bone Loss

Abstract

As the number of total elbow arthroplasty (TEA) continues to increase worldwide, one might predict the number of revision TEA would rise as well. The most common indications for revision TEA include (a) loosening, (b) infection, and (c) periprosthetic fracture. Although the rate of revision TEA procedures continues to rise due to the infrequency in which they are performed compared to other arthroplasty surgeries, no gold standard algorithm or procedure for managing severe ulnar bone loss in revision TEA has been determined. Various surgical techniques and strategies including allograft-prosthesis composite, custom long prosthesis with or without allograft, and resection arthroplasty have all been employed in attempting to address severe ulnar bone loss in revision TEA. Though the reported outcomes are mixed at best between each treatment strategy with similar complication rates. Another option is implanting the ulnar component into the radius. In those patients with severe ulnar bone loss, a humeroradial TEA revision can provide stability, restore range of motion, and provide pain relief.

Introduction

The number of total elbow arthroplasties (TEA) continues to rise in the United States alone; there has been a threefold increase in primary TEA from 1993 to 2007. ¹ End-stage rheumatoid elbow disease has been a well-established indication for TEA. However, the indications for TEA have been expanded to include osteoarthritis, posttraumatic arthritis, and acute distal humerus fractures. ² With the expanding indications for TEA and the increasing prevalence of total elbow arthroplasties, a rise in the number of revision TEA procedures is anticipated. ³ The most common indications to proceed with a revision TEA are the following: (a) aseptic loosening, (b) infection, and (c) periprosthetic fracture. ⁴ The principles of managing any revision arthroplasty surgery are the same no matter the revision: preoperative planning, preserving soft tissues, protecting nerves and arteries, preserving bone, and always considering the future.

When considering TEA revision surgery, large ulnar defects present a particularly complex reconstructive problem, and the data to guide treatment in this setting is scarce. A number of surgical options have been described, including custom long stem components, cancellous autograft, impaction grafting, allograft-prosthesis composite, ⁵ resection arthroplasty, ⁶ and cortical strut allografts. ⁷ These procedures are technically challenging, produce varying results, and are plagued with high complication rates, leaving room for the development of new procedures to address this exceedingly difficult problem. The purpose of this report is to present a novel technique for humeroradial TEA revision when encountering significant ulnar shaft defects. We present our technique along with case reports from three patients.

Technique

Clinical Evaluation

Patients who present with concern for either an infected, loosening, or periprosthetic fracture of a TEA should first be evaluated with a history and physical examination. Questioning should be directed on the history of symptoms, mechanism of injury if applicable, and current functional status. The physical examination should focus on passive and active range of motion (ROM), the patient's perceived level of pain at rest and with activity, and assess the patient's neurovascular status along with appropriate radiographic evaluation of the affected elbow.

Setup and Approach

The patients are positioned in the lateral decubitus position with the operative extremity cradled in a post or supported by a sterile bump. The previous posterior incisions were identified and utilized. The ulnar nerve was systematically released and was anteriorly transposed if it had not been previously transposed. The triceps are then split in line with the ulna and dissected away, making full-thickness tricep flaps, which are retracted from the proximal ulna to complete the exposure.

Preparation and Implantation

With the exposure complete, the humeral component is then evaluated for stability. The components are then unlinked, the ulnar component is extracted, and the cement mantle is removed using a combination of osteotomes and curettes. A reciprocating saw removes the radial head by cutting through the radial neck. A canal-finding reamer and appropriate broaches are used to prepare the radial canal for the ulnar component. One technical pearl for this procedure is; due to the bow of the radius, depending on the implant manufacturer, certain implants require instrumentation designed for the contralateral side. The trial component is then placed into the radius and tested for joint stability in addition to assessing the ROM. Once the appropriate size is determined, cement is introduced into the canal. After insertion of the prosthesis, the elbow is extended with slight forearm pronation until the cement has cured.

Closure

Meticulous soft tissue closure is paramount to preventing complications postoperatively. We repair the subperiosteal envelope, including the triceps, using a Tevdek or Ethibond suture. A hemovac drain is then placed when there is a concern for postoperative hematoma. The subcutaneous tissues are approximated and the skin is closed and the wound is dressed with a well-padded posterior splint.

Postoperative Care

Patients are seen within seven days postoperatively to remove their dressings and begin to work with physical therapy. Patients receive a hinged elbow brace along with a detailed treatment plan and protocol for rehab at this visit.

Case Examples

Patient A

Patient A is a 52-year-old male who underwent a primary TEA with a subsequent ulnar nerve transfer performed for a persistent radial nerve palsy after a traumatic injury to his left elbow approximately 3 years prior, all performed at a separate facility. The patient initially first presented to our outpatient clinic 3 weeks after having sustained a fall onto his left elbow while climbing out of a pool with a chief complaint of left elbow pain. Imaging revealed a periprosthetic fracture with a complete dislocation of the ulnar stem from the hinge complex (Figure 1A). The patient, on presentation, could not extend his wrist or thumb and had significantly diminished sensation in all dermatomes of the left hand, though this was consistent with his functional status prior to his recent fall. The decision to leave the broken radial stem in place was made after considering that the stem was not prominent or at risk of causing damage to surrounding tissues. Additionally, it was found to be well seated within the radius; any attempt to remove it would only cause further bone loss. The patient had no significant postoperative events through his 1-week postoperative visit up until his last reported follow-up at 1 year (Figure 1B). At the patient's last follow-up, he reported a 2/10 pain with 115° of flexion and 20° extension active ROM at the elbow. The patient's previous radial nerve deficits were still present at his final follow-up and were being managed with bracing.

Figure 1.

(A) Radiograph demonstrating a periprosthetic elbow fracture. (B) Radiographs of the left elbow of patient A demonstrating a humeroradial total elbow revision arthroplasty with retained stem in the ulna.

Patient B

Patient B is a 67-year-old male who presented 7 years after a primary TEA after a traumatic injury to his left elbow. He was seen for follow-up with a chief complaint of new onset swelling and pain in his left elbow (Figure 2A). The patient underwent several subsequent irrigation and debridement procedures with placement of antibiotic beads and cue ball arthroplasty and with multiple courses of antibiotics. At the time of his final revision operation, the bone quality of the ulna was deemed to be too poor for reimplantation of the distal component. Postoperatively, the patient had no issues from his 1-week postoperative visit through his 1 year postoperative visit (Figure 2B). At 2 years postop, the patient reported a 0/10 pain with a flexion of 120° and extionsion of 15° active ROM.

Figure 2.

(A) Radiograph at 7 years postop primary total elbow arthroplasty. (B) Radiograph demonstrating a well-fixed humeroradial total elbow revision arthroplasty.

Patient C

Patient C is a 58-year-old female with the most complex patient presentation in this report. The patient underwent a primary TEA due to end-stage rheumatoid arthritis of the elbow, who had and was taking disease-modifying anti-rheumatic drugs (DMARD). The patient was noncompliant with her postoperative wound care protocol and subsequently underwent numerous irrigation and debridements. The patient continued to experience issues with her wound and TEA with repeat infections; therefore, the decision was made to remove her hardware. She then underwent subsequent irrigation and debridement with the placement of antibiotic beads along with cue ball arthroplasty and was treated with several courses of outpatient antibiotics. At the time of her final revision, the quality of the cortical bone of the ulna, along with the significant bone defect noted at that time, the physician elected to proceed with the aforementioned technique (Figure 3A). The patient had no issues postoperatively from her 1-week visit through 6 months postop as she progressed in a stepwise manner(Figure 3B). At the patient's 1 year postop visit, she did endorse persistent pain (4/10) and reduced active ROM (100° flexion and 20° extension) the patient had no clinical indications of infection or loosening at that time. The decision was made to continue to monitor her symptoms and to follow-up at 15 months postop or sooner if warranted. The patient, unfortunately, experienced a ground-level fall within 14 months after the salvage procedure and sustained a periprosthetic fracture around the stem within the radius. The patient underwent revision surgery for a periprosthetic fracture. A 155 mm revision stem was placed into the ulna and secured proximally with a radial strut autograft, which was secured with two cerclage wires.

Figure 3.

(A) Initial radiograph demonstrating the primary total elbow arthroplasty. (B) Postoperative imaging demonstrating well-fixed humeroradial total elbow revision arthroplasty.

Discussion

TEA failures with ulnar bone loss are a particularly difficult surgical problem because both the distal fixation site for the prosthesis and the triceps attachment are compromised. Several etiologies of ulnar bone loss have been described, including component loosening with associated osteolysis, periprosthetic ulnar fracture (via trauma or intraoperatively while removing an infected prosthesis or cement), and osteomyelitis of the ulna. ² Treatment options have traditionally included allograft-prosthesis composite, custom long prosthesis with or without allograft, and resection arthroplasty. ² Allograft-prosthesis composite revisions have had promising results but are plagued with complications including bone resorption, fracture, infection, nonunion. ⁵ Mansat found a nearly 25% rate of deep infection in their case series of allograft-prosthesis composites. ⁵ Revision with long stem components with strut allografts or impaction grafting is another surgical option. ⁸ In a study performed at Mayo Clinic, Kamineni et al reviewed 22 elbows treated with strut grafts and combined strut and impaction grafting which resulted in improved functional scores rated good or excellent in 12. ⁸ However, there was a relatively high rate (36%) of complications that required additional surgical intervention. Concerns with strut allografts include infection, nonunion, and decreased strength and subsequent fracture. ⁸ In patients undergoing revision TEA another potential choice is resection arthroplasty. A retrospective analysis of 51 patients who underwent resection arthroplasty for deep TEA implant infections reported half of the patients who were evaluated for long-term follow-up had a stable elbow. Yet, 47% of them required additional surgeries due to infection and 24% of them experienced wound complications. ⁶

Humeroradial TEA revision for addressing severe ulna bone loss has been previously reported in the literature with a relatively low number of cases and various indications for each revision.^9–11 The prior reports all successfully detailed the restoration of a functional TEA following humeroradial TEA revision for severe ulnar bone loss with no major complications. In the current study, the technique provided both patient A and patient B improvement in pain with active ROM and a functional arc of motion. Yet, patient C, the only patient who had a primary TEA due to rheumatoid with multiple revisions due to infection, reported at 1 year to still be painful and have decreased ROM. At 1 year postoperation, none of the patients required further revisions due to either infection or loosening.

Limitations

We acknowledge that our study did not report patient functional outcomes; we used mobility to live independently as a surrogate marker of this. Revising the ulnar component into the radius provided patients with functional flexion and extension and did not greatly worsen their pronation or supination compared to their baseline.

Conclusion

Ultimately, there is no consensus on an optimal treatment algorithm for revision TEA with significant ulnar defects; the presented technique has shown to be a viable option, resulting in a stable prosthesis with restored function without significant complications.