Efficacy of 2-stage revision using a prosthesis of antibiotic-loaded acrylic cement spacer with or without cortical strut allograft in infected total elbow arthroplasty.

PURPOSE: We aimed to evaluate the efficacy of a self-manufactured prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) spacer with or without cortical strut allograft in infected total elbow arthroplasty. METHODS: Between March 2009 and February 2018, we enrolled 18 patients (mean age, 66.9 years) who underwent 2-stage revision arthroplasty for prosthetic infection following total elbow arthroplasty. After implant removal in the first stage, we performed débridement and PROSTALAC insertion. During the second stage, we performed reimplantation using a cortical strut allograft for patients with a considerably severe bone defect. The mean follow-up period was 34 months (range, 25-60 months), during which we evaluated the Mayo Elbow Performance Score (MEPS), range of motion (ROM), and blood markers. RESULTS: In all 18 patients, infection control was ensured using intravenous (IV) antibiotic therapy for 6 weeks or IV antibiotics for 4 weeks converting to oral antibiotics for 2 weeks following PROSTALAC insertion. The mean visual analog scale score improved from 8 points preoperatively to 2 points postoperatively, and the mean MEPS improved from 32 points preoperatively to 82 points postoperatively (P < .05). The average ROMs at the last follow-up were 9° to 132° from extension to flexion, respectively. Two patients experienced ulnar nerve neuropraxia after surgery, from which they were resolved. Moreover, 2 and 4 patients developed superficial wound infection and triceps insufficiency, respectively, and there was no infection recurrence. CONCLUSION: In the management of elbow prosthetic infection, 2-stage revision arthroplasty using PROSTALAC spacer insertion in the first stage and cortical strut allograft in the second stage for patients with severe bone defect revealed good clinical results and relatively low infection recurrence rates. However, the complication rate is substantial.

Humeral amputation following total elbow arthroplasty.

PURPOSE: Total elbow arthroplasty (TEA) is associated with a relatively high complication rate, and exceptionally catastrophic complications might lead to amputation. The purpose of this study was to determine the incidence and aetiology of amputation performed at our institution in upper extremity limbs with a prior TEA. METHODS: Between 1973 and 2018, 1906 consecutive TEAs were performed at our institution. Upper extremity amputation was performed in seven (0.36%) elbows with five transhumeral amputations and two shoulder disarticulations. The group consisted of five females and two males with a mean age of 64 years (range, 37-80). The index TEA had been performed for rheumatoid arthritis (n = 2), rheumatoid arthritis with acute fracture (n = 2), radiation associated nonunion (n = 2), and metastatic cancer (n = 1). Mean follow-up after amputation was three years (range, 3 months-5 years). RESULTS: Mean time between amputation and TEA was 5 years (range, 2 months-13 years). The indications for amputation included uncontrolled deep infection in six (86%) elbows and tumor recurrence in one (14%) elbow. Only one elbow (14%) was fitted with a prosthesis. Six (86%) patients died at a mean of three years (range, 3 months-5 years) after amputation. CONCLUSION: The results of this study highlight a low incidence of amputation after TEA. Most amputations were the direct result of TEA complications, with infection being the most common cause of amputation. Outcomes after amputation are concerning, with poor overall survival and few patients being fit for a prosthesis.

Relationship between the tilt angle of bipolar radial head prostheses and radiological radiocapitellar instability.

OBJECTIVE: This study aimed to radiologically assess the relationship between the tilt angle of the bipolar radial head prostheses and radiocapitellar instability. METHODS: In this radiological study, 28 consecutive patients (13 females and 15 males: mean age=47 years and age range=23-77 years) who underwent cemented bipolar radial head arthroplasty (Judet CRF II) because of comminuted radial head fracture with elbow instability were retrospectively reviewed. RESULTS: There was excellent intra- and interobserver reliability for the measurements of the tilt angle and the radiocapitellar distance. ICC for interobserver reliability of the tilt angle was 0.93, and ICC for intraobserver reliability for the 2 observers was 0.96 and 0.97, respectively. ICC for interobserver reliability of the radiocapitellar distance was 0.87, and ICC for intraobserver reliability for the 2 observers was 0.91 and 0.93, respectively. The mean tilt angle was 17.6° (range=1°-35°), and the mean radiocapitellar distance was 8 mm (range=1-17 mm). Pearson's correlation revealed a strong significant positive correlation between the tilt angle and the radiocapitellar distance (r=0.77 and p<0.001). CONCLUSION: Evidence from this study has demonstrated a strong positive correlation between the tilt angle of bipolar radial head prostheses and radiocapitellar instability. The tilt angle can be used as an indicator of radiocapitellar joint instability following bipolar radial head prostheses. LEVEL OF EVIDENCE: Level IV, Diagnostic study.

Quantitative ultrahigh-molecular-weight polyethylene wear in total elbow retrievals.

BACKGROUND: The purpose of this study was to evaluate ultrahigh-molecular-weight polyethylene (UHMWPE) wear and damage from retrieved total elbow arthroplasty components and compare in vivo wear with wear produced in vitro. METHODS: Explanted total elbow components were collected at revision surgery. UHMWPE damage was characterized visually, whereas penetration and wear were quantified using micro-computed tomography and gas pycnometry. Volumetric wear rates were compared with historical hip data, and wear data were compared with reported in vitro wear test data. RESULTS: Humeral bushing damage primarily occurred in the form of burnishing, scratching, and pitting at the articular face in the region of contact with the ulnar component. Wear of the ulnar bushings was concentrated on the edge of the component at the point of contact with the axis pin. Pitting and embedded debris were dominant damage modes, in addition to burnishing and delamination. Backside wear was negligible. The median linear penetration rates of the lateral, medial, and ulnar bushings were 0.14 mm/yr (range, 0.01-0.78 mm/yr), 0.12 mm/yr (range, 0.03-0.55 mm/yr), and 0.11 mm/yr (range, 0.01-0.69 mm/yr), respectively. The volumetric wear rates of the lateral, medial, and ulnar bushings were 5.5 mm3/yr (range, 0.7-37.2 mm3/yr), 5.9 mm3/yr (range, 0.6-25.5 mm3/yr), and 5.5 mm3/yr (range, 1.2-51.2 mm3/yr), respectively. CONCLUSIONS: The observed wear rates were similar to those reported in well-functioning total hip replacement patients with conventional UHMWPE bearings. We found limitations in reported in vitro testing resulting in wear that was not consistent with our retrieval data. We recommend further investigation to clinically validate in vitro simulation to provide appropriate loading protocols for elbow wear simulation.

Treatment of elbow periprosthetic joint infection: a systematic review of clinical outcomes.

BACKGROUND: Periprosthetic joint infection (PJI) of the elbow is a relatively common complication after total elbow arthroplasty (TEA), and its treatment is frequently variable. Few articles have provided direct comparisons of outcomes, making it difficult to draw conclusions from the available literature. This systematic review synthesizes the English-language literature on elbow PJI to quantify treatment outcomes. METHODS: The PubMed and Scopus databases were searched in December 2018. Our review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Keywords included "elbow replacement infection" and "elbow arthroplasty infection." A total of 1056 titles were identified; after application of the exclusion criteria, 41 studies met the screening criteria and underwent full-text review. Fifteen articles were included for the final analysis regarding demographic characteristics, risk factors, infecting organisms, success of eradication of infection based on surgical method, and functional outcomes of specific treatment regimens. RESULTS: Among the 15 articles selected, there were 309 TEA infections. Staphylococcus aureus was the most frequently isolated organism (42.4%), followed by coagulase-negative staphylococci (32.6%). Risk factors for the development of elbow PJI included rheumatoid arthritis, steroid use, an immunocompromised state, and previous elbow surgery. The rate of successful infection eradication was highest with 2-stage revision (81.2%) and lowest with irrigation and débridement for component retention (55.8%). The level of evidence was IV in 14 studies and III in 1 study. CONCLUSIONS: In this systematic review of TEA infections, Staphylococcus species represent the most common infecting organism. Two-stage revision was the most effective treatment for elbow PJI, showing the lowest recurrence rate for infection.

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.

Long-term outcomes after Instrumented Bone Preserving total elbow arthroplasty: a radiostereometric study with a minimum follow-up of 10 years.

BACKGROUND: Aseptic loosening is a main concern in elbow arthroplasty. Evaluation of implant migration using radiostereometric analysis (RSA) might increase understanding of implant loosening. Previously, 2-year RSA results of 16 Instrumented Bone Preserving (IBP) elbow prostheses showed migration of the humeral component in the first weeks but most components stabilized within 6 months postoperatively. In follow-up, the present study evaluated long-term survival, the relation between early migration and survival, and the long-term migration and clinical outcomes. METHODS: Sixteen patients who received an IBP prosthesis were prospectively followed with a median follow-up time of 136 months (range 82-165). Migration was measured using RSA. Clinical results were described using the Elbow Function Assessment (EFA), Broberg and Morrey elbow functional rating index, Oxford Elbow Score (OES), and visual analog scale (VAS) for pain and satisfaction. RESULTS: Four patients underwent a revision within 10 years, and 2 more were planned for revision surgery after 14 years. Five patients died with their prosthesis in situ. Early migration was not associated with survival. Long-term migration patterns varied widely. Median EFA score was 58.5, Broberg and Morrey score was 50, and OES score was 32. Median VAS score for pain was 2 and that for satisfaction was 7.5. CONCLUSION: Ten-year survival of the IBP total elbow prosthesis was 75%, decreasing to 63% after 14 years of follow-up. Long-term implant failure could not be predicted by 2-year migration results in this study. Although short-term clinical results were promising, long-term outcomes worsened in all patients.

Management of rheumatoid arthritis of the elbow with a convertible total elbow arthroplasty.

BACKGROUND: Total elbow arthroplasty (TEA) is commonly performed in patients with rheumatoid arthritis (RA). The purpose of this study was to compare outcomes and complications of unlinked and linked TEA using a convertible system in patients with RA. METHODS: All patients with RA who underwent TEA at a single center with a minimum of 2 years' follow-up were reviewed. Demographic information, patient-reported outcome scores, functional outcome assessments, and radiographic parameters were evaluated at most recent follow-up. RESULTS: We evaluated 82 patients (27 with unlinked TEA and 55 with linked TEA) with RA. The mean age at surgery was 61 ± 10 years, with a mean follow-up period of 6 ± 4 years. Demographic characteristics were similar between groups, with the exception of longer follow-up in the unlinked group (8 years vs. 5 years, P = .001). No differences in range of motion were noted. Elbow strength was similar other than pronation strength (74% ± 8% for unlinked vs. 100% ± 8% for linked, P = .03). The mean Mayo Elbow Performance Index was 83 ± 16; Patient Rated Elbow Evaluation score, 15 ± 18; and QuickDASH (short version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score, 34 ± 20. No differences in the rates of reoperation (17% vs. 24%, P = .4), complications (32% vs. 31%, P = .4), or revisions (13% vs. 17%, P = .3) were found between unlinked and linked devices. Four patients with instability, all with unlinked designs, underwent revision to a linked design. Four patients, all with linked designs, underwent revision for aseptic loosening of smooth short-stem ulnar components. CONCLUSION: TEA using a convertible implant design provides good patient-reported outcomes at mid-term follow-up in patients with RA. Our study was unable to detect a difference in the use of either unlinked or linked implant designs; further large comparison trials are needed.

Long-term results of the iBP elbow prosthesis: beware of destructive metallosis!

BACKGROUND: The aim of this study was to review the long-term results of the instrumented Bone Preserving (iBP) elbow prosthesis. METHODS: Thirty-one patients (10 M, 21F, 28-77 year) were retrospectively evaluated using the Oxford Elbow Score (OES), Disabilities of Arm, Shoulder and Hand Outcome Measure (DASH), Mayo Elbow Performance (MEPS), physical examination and standard radiographs. Kaplan-Meier survival analysis was used. RESULTS: Thirty-seven primary iBPs have been placed in 31 patients between 2000 and 2007. Six patients (8 prostheses) had died, 10 elbows had been revised and three patients (4 prostheses) were lost to follow-up. Fourteen patients (15 prostheses) were available for follow-up. The main indication for surgery was rheumatoid arthritis. Mean follow-up was 11 years (8-15). Kaplan-Meier survival analysis showed a survival of 81% at 10 years after surgery. Main reason for revision was particle disease and loosening due to instability and malalignment. Eleven of 14 patients were satisfied, although radiographs showed radiolucencies in 11 patients. CONCLUSION: The iBP elbow prosthesis gives a survival rate of 81% 10 years after surgery with a progressive decline beyond 10 years. However, many patients have radiolucencies. Discrepancy between clinical signs and radiological results warrants structural follow-up, to assure quality of bone stock in case revision surgery is indicated. The study was reviewed and approved by the Medical Ethical Committee of University Medical Center Groningen (METc2016/038). LEVEL OF EVIDENCE: Level IV, Case series.

Clinical results of revision total elbow arthroplasty: comparison of infected and non-infected total elbow arthroplasty.

BACKGROUND: Total elbow arthroplasty (TEA) is considered a successful treatment for several conditions, including rheumatoid arthritis and comminuted fractures. However, failure rates as high as 62% have been reported, with many patients requiring surgical revision. Causes of failure requiring revision can be classified as infected or non-infected. This study evaluated the clinical and radiologic outcomes of TEA revision surgery according to causes of failure. METHODS: Twenty patients undergoing revision TEAs in 2010-2015 were retrospectively evaluated. Mean follow-up was 52.7 months. Patients were categorized into infected and non-infected groups based on radiologic and serologic tests. Clinical outcomes included range of motion (ROM) and Mayo Elbow Performance Score (MEPS), and radiological outcomes included loosening signs on anteroposterior (AP) and lateral plain radiographs at final follow-up. Complications were assessed in both groups. RESULTS: Overall, mean MEPS was 79.7, and mean ROM arc was 97.9° at final follow-up. Nine patients underwent revision due to infection, and 11 due to non-infectious causes. Mean MEPS in these two groups was 75.6 and 83.5, respectively, and mean ROM arc for flexion-extension was 89.4° and 108°, respectively. Two (22%) of the nine patients in the infection group required second revision surgery due to recurrent infection. No patient in the non-infected group underwent second revision surgery. The most frequent complication in the infected group was osteolysis, observed in five patients, including four with symptomatic aseptic loosening and one with non-symptomatic osteolysis. Two patients in the non-infected group demonstrated a non-progressive radiolucent line, which was asymptomatic at final follow-up. CONCLUSION: Revision TEA provided clinical improvement in elbow function and resulted in satisfactory outcomes. Outcomes were worse in the infected than in the non-infected groups. Comorbidities and older age were apparent risk factors for infected TEA.

Failure of Adjustably Aligned Modular Radial Head Arthroplasty With Head-Neck Dissociation and Metallosis.

Radial head arthroplasty was introduced in 1941 and the literature supports satisfactory overall midterm patient outcomes and acceptable complication profiles with several models. There are several previously described mechanisms by which radial head complications typically occur. We present the case of a rarely described mechanism of radial head implant failure: elbow synovitis and pain from partial dissociation and metallosis in an adjustably aligned, modular, monopolar, mixed metal, press-fit radial head arthroplasty.

Complications after radial head arthroplasty: a comparison between short-stemmed bipolar and monopolar long-stemmed osteointegrative rigidly fixed prostheses.

INTRODUCTION: To date, only a few studies have compared radial head prostheses (RHP) and their different anchoring principles. The aim of this study was to characterize concomitant injuries, necessary adjuvant procedures, complications, and radiological findings after implantation of two different types of RHP. METHODS: Sixty-six patients with radial head fractures were treated with MoPyC (Tornier/France, 50 mm stem, monopolar) or SBI rHead prostheses (Small Bone Innovations/USA, 22-mm stem, bipolar) and followed up over 42 months (16-64 months). Primary objective was the detection of different loosening and explantation rates. In addition to the revision rate and the reasons for revision, we also used radiological findings to assess the dynamics of lysis phenomena. RESULTS: Thirty-five patients (mean age 48 years; 22-73 years) were treated with the MoPyC, and 31 patients (mean age 47 years, 19-69 years) with the rHead prosthesis. Of these, 98% had a Mason 3 or 4 type of radial head fracture, and 94% showed concomitant injuries, which were addressed in 89% of cases by adjuvant procedures. The surgical revision rate was 20% (rHead 23%; MoPyC 18%). Significantly more of the rHead prostheses had to be explanted compared to MoPyC prostheses because of painful loosening (16% vs. 3%; p = 0.029). Predictors of subsequent loosening were significant radiolucent lines in the RHP over the first six months and an increase in width by two and a half times within the first 50 days after implantation. CONCLUSION: Complex radial head fractures are frequent and difficult to treat. The monopolar long-stemmed prosthesis showed significantly lower rates of painful loosening and explanation rates than the bipolar short-stemmed prosthesis.

Timely recognition of total elbow and radial head arthroplasty adverse events: an analysis of reports to the US Food and Drug Administration.

BACKGROUND: Recent recalls of several commonly used elbow arthroplasty implants have prompted interest in the modes by which elbow implants fail and the timing of reports of these failures. METHODS: We reviewed the adverse event reports to the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database from 2012 to 2015 regarding elbow arthroplasty to determine the event date and the type of each adverse event. RESULTS: Among 179 total elbow adverse event reports, the most common modes of failure were implant dissociation (23%), loosening (22%), and infection (16%). The most common modes of failure among 58 radial head replacement reports were component dissociation (19%) and linkage screw failure (19%). The percentage distribution of adverse event types differed among different arthroplasty systems and from that reported in published reviews of elbow arthroplasty. Three implant recalls were implemented 2, 5, and 9 years after the first adverse event report in the MAUDE database. For 2 of the recalls, the first reports of the device failures were published 2 and 5 years after the first MAUDE reports. CONCLUSIONS: The MAUDE database is a publicly funded and publicly available means by which surgeons can identify adverse events for the prostheses they use before such information becomes available through journal publication or recall notification. In this study, MAUDE data revealed a higher relative frequency of mechanical dissociation of elbow implants than what has been represented in the literature. Early identification of these adverse events may help surgeons by informing their implant selection and surgical technique.

Long-term outcome of custom triflange outrigger ulnar component in revision total elbow arthroplasty.

BACKGROUND: Patients missing the distal humeral condyles are prone to premature bushing wear after total elbow arthroplasty. A midterm study has demonstrated that a custom triflange outrigger ulnar component was successful in preventing this. The aim of this study was to determine whether these results remained stable over time. MATERIALS AND METHODS: The outcomes of 6 patients who underwent revision of a loose ulnar component using a custom triflange outrigger component were reviewed in this retrospective case study. The average patient age at the time of revision was 51. The average number of prior operations was 2 (range, 1-3). The mean follow-up was 15 years (range, 10-18 years). RESULTS: At final follow-up, the mean range of extension-flexion was 35° to 135°, and pronation-supination was 65° to 63°. The average Mayo Elbow Performance Score improved to 75 of 100. Four implants were still in place with no radiolucencies or osteolysis. Three patients required revision surgery for broken humeral stems. Two required conversion to another total elbow arthroplasty system after 18 and 14 years for humeral component loosening. CONCLUSIONS: These components lasted an average of 4 times longer than the original ulnar components. In our experience, periarticular osteolysis caused by polyethylene wear creates a region of unsupported stem and a stress riser at the junction with the remaining well-supported stem and causes component stem fractures. The concept of an outrigger type of hinge might be useful for active patients requiring an elbow prosthesis in the setting of deficient condyles.

Short to midterm outcomes of one hundred and seventy one MoPyC radial head prostheses: meta-analysis.

BACKGROUND: The MoPyC implant is an uncemented long-stemmed radial head prosthesis that obtains primary press-fit fixation via controlled expansion of the stem. Current literature regarding MoPyC implants appears promising; however, sample sizes in these studies are small. Our primary objective was to evaluate the short- to midterm clinical outcomes of a large sample of the MoPyC prostheses. The secondary objective was to determine the reasons for failure of the MoPyC devices. METHODS: Four electronic databases were queried for literature published between January 2000 and March 2017. Articles describing clinical and radiographic outcomes as well as reasons for reoperation were included. A meta-analysis was performed to obtain range of motion, mean Mayo Elbow Performance score (MEPS), radiographic outcome, and reason for failure. RESULTS: A total of five articles describing 171 patients (82 males) with MoPyC implants were included. Mean patient age and follow-up were 52 years (18-79) and 3.1 years (1-9), respectively. Midterm clinical results were good or excellent (MEPS > 74) in 157 patients. Overall complication rate was low (n = 22), while periprosthetic osteolysis was reported in 78 patients. Nineteen patients returned to the operating room, with implant revision being required in ten patients. The two primary reasons for failure were (intra-)prosthetic dislocation (n = 8) followed by stiffness (n = 7); no painful loosening was described. CONCLUSION: Short- to midterm outcomes of MoPyC prostheses are satisfactory and complications associated are low. The use of stem auto-expansion as a mode of obtaining primary fixation in radial head arthroplasty appears to be an effective solution for reducing the risk of painful loosening.

Macroscopic investigation of failed Kudo type 5 total elbow arthroplasty.

BACKGROUND: On the basis of the intra-articular findings during Kudo type 5 elbow prosthesis revision surgery, we infer the mechanisms leading to implant failure. MATERIALS AND METHODS: We performed primary Kudo type 5 total elbow arthroplasty on 60 rheumatoid elbows in 45 patients between 1994 and 2003. Revision surgery was performed in 8 patients (9 elbows) because of implant failure. We radiographically assessed their status before this surgical procedure and then assessed the surgical intra-articular findings based on surgery records and photographs. RESULTS: In all cases, revision surgery was necessitated by failure of the ulnar component. There were 2 types of implant failure: fracture of the ulnar component neck (n = 3) and loosening of the ulnar component (n = 6). In the latter group, 2 elbows exhibited valgus deformity of the retrieved ulnar component. There were no cases of metallosis or wear of the articular surface. CONCLUSION: This study describes the types of implant failure in unlinked Kudo type 5 total elbow arthroplasties with all-polyethylene ulnar components based on the intra-articular findings. Failure of the all-polyethylene ulnar component could have been caused by ulnar neck distortion that occurred prior to polyethylene wear on the joint surface. In addition, valgus stress on the elbow joint may have contributed to these implant failures.

Treatment of periprosthetic joint infection of the elbow: 15-year experience at a single institution.

BACKGROUND: Total elbow arthroplasty (TEA) can be complicated by periprosthetic joint infection (PJI) with potentially catastrophic failure. The purpose of this study was to describe the results of elbow PJI treatment at a tertiary-care referral center. METHODS: An institutional TEA database was queried for infection and reoperation after TEA. Patients who underwent irrigation and débridement (I&D) with component retention were compared with those who underwent component explantation, antibiotic spacer placement, and reimplantation of a revision TEA. RESULTS: A total of 26 patients (10 men; mean age, 64.3 years) were treated for PJI of TEA. There were 3 polymicrobial infections (11.5%) and 13 Staphylococcus aureus infections (50%) (4 methicillin resistant); 6 patients (23.1%) had negative culture results. Ten patients (38.5%) underwent I&D and component retention, with 5 of those patients (5 of 10, 50%) having recurrent infection at an average of 3.1 years (range, 0.25-7.8 years) after I&D. Of 16 patients who underwent antibiotic spacer placement, 12 (75%) underwent 2-stage reimplantation of a TEA. Among those with reimplantation, 4 of 12 (33.3%) required reoperation. In 3 of 12 (25.0%), reoperation was required for infection, whereas 1 of 12 (8.3%) required surgery for mechanical complications. CONCLUSION: Two-stage revision results in a decreased rate of recurrent PJI. Certain patients (those with poor health or well-fixed components) may be more suitable for I&D and component retention, with a demonstrated 50% success rate over a period of 3 years. Longer-term follow-up may result in higher reinfection rates in both groups.

Capitellar erosion after radial head arthroplasty: A comparative biomechanical study of operated radial head fractures on cadaveric specimens.

BACKGROUND: We asked whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA), common techniques used for the confrontation of displaced or comminuted radial head fractures, are correlated with cartilage wear of the capitulum. HYPOTHESIS: We hypothesized that neither ORIF nor RHA are correlated with capitellar cartilage wear. MATERIAL AND METHODS: On 5 cadaveric elbow specimens, osteotomies were employed to simulate radial head comminuted fractures followed with ORIF by Herbert screws. Radial heads were also excised from other 5 cadaveric elbow specimens and were replaced by metallic monopolar implants. Finally, 2 elbows were not operated and used as a control group. Custom-made rotary machines, working unstoppably, generated 700,000 pronation and supination forearm movements at a 110° arc of motion. The elbow joints were examined with pre- and postoperative magnetic resonance imaging (MRI) scans and the articular surfaces of the capitula were resected and sent for histopathology study. RESULTS: In the 2 cadaveric elbows of the control group and the 4 elbows treated with ORIF, no cartilage damage was found. The fifth one displayed cartilage fissures, which were, classified according to International Cartilage Repair Society (ICRS) grading system as grade I cartilage damage. On the contrary, all 5 elbows treated with RHA sustained complete cartilage loss, exposure of the subchondral bone and were classified as ICRS grade IV cartilage damage. DISCUSSION: Our study suggests that metallic monopolar RHA after a displaced or comminuted radial head fracture carries a high risk of rapidly evolving cartilage loss of the capitulum.

Trends in total elbow arthroplasty: a nationwide analysis in Germany from 2005 to 2014.

PURPOSE: To date, there has been no study investigating the epidemiology and the changes over time, especially regarding indications, in total elbow replacement in Germany. METHODS: Using German procedure classification system (OPS) codes as well as the associated ICD codes, a retrospective analysis from 2005 to 2014 of the data provided by the Federal Statistical Office of Germany was performed. Total elbow arthroplasties (TEAs) were evaluated for admitting diagnoses, sex, and age of patient and distribution of constraint versus unconstraint prostheses. Furthermore, the number and indications of revision elbow arthroplasty (REA) and explantations were identified. RESULTS: From 2005 to 2014, a total of 3872 patients underwent TEA in Germany. This represents a rise of 84% in this period. Almost 77% of the arthroplasties were performed in females, and over 45% were implanted in patients before the age of 70. During the study, a significant increase in TEA performed on patients for trauma from 12 to 42% and concomitantly, a decrease for the arthritis subgroup from 20 to 2.6% could be revealed. Additionally, almost a doubling of REA in that period could be detected (10.3 to 17.1%). The main revision indication could be found in mechanical complications, such as aseptic loosening (72.1%). Conversely, the number of explantations decreased (12.4 to 5.8%). CONCLUSION: During the study period, the number of TEA performed in Germany nearly doubled. Over the years, the most common indication for total elbow arthroplasty changed from inflammatory arthritis to trauma sequel. Further database analysis may help to identify populations at risk and specify reasons for revisions. LEVEL OF EVIDENCE: Therapeutic Level IV.

Postoperative Infection Related with the Total Elbow Arthroplasty (Kudo's Prosthesis) in Rheumatoid Arthritis.

BACKGROUND: Total Elbow Arthroplasty (TEA) for the rheumatoid arthritis (RA) has been popularized since 1980s. The outcomes of TEA using any type of implant design for RA has been satisfactory. On the other hand, many orthopedicians experience several postoperative complications. Among them, postoperative infection has still being the most troublesome and difficult to treat. This study is to clarify the causes of postoperative infection of TEA using Kudo's prosthesis for RA and discuss how to manage and prevent infection. METHODS: 421 TEAs were performed for 405 cases with RA at the authors' institute during the period between 1982 and 2007. They were followed up for 1~25 years (Av. 12.3 years). The authors examined pain, the range of motion, roentgenograms and complications postoperatively. We were able to start treatment within 4 weeks after occurrence of infection. For surgical management of infected TEAs, debridement of the synovium and removal of the prosthesis with loosening were performed for all cases. In addition, all cases have been regularly and strictly followed-up with the elbow protector to prevent recurrence of infection since 2008. RESULTS: There were 98 TEAs with the postoperative complications (23.3%). Eight out of 98 TEAs were infected (1.9%). Five of eight infected TEAs were primarily at the surgical scar site infection (SSSI) (60%), unknown causes in two, hematogenous course in 1. It's obvious that surgical scar site infection (SSSI) was the leading cause of postoperative infection in this study. Thus, the authors made the elbow proctor to avoid injuries of the skin around surgical scar site (SSS). Since 2008, all of the TEAs and revised TEAs have been applied with this protector. CONCLUSIONS: The authors reported 8 infected TEAs: 5 cases were revised, 2 with the brace, 1 had above the elbow amputated. The regular and meticulous follow up and application of the elbow protector were useful to prevent infection of post-TEAs using Kudo's prosthesis in RA. Since 2008, there have been no infection of post TEAs and revised TEAs.