Revision total elbow replacement.

ABSTRACT

The range of general and specific adverse event in total elbow arthroplasty is similar in principle and practice to all other revision prosthetic arthroplasty but with three particular challenges loss of humeral and ulnar bone stock; insufficiency of the extensor 'mechanism'; and the management of the ulnar nerve. Total elbow replacement is presently performed for the management of complex non-reconstructable distal humeral fractures in osteoporotic bone, for post-traumatic arthropathy, and for medically managed inflammatory arthritides in which metaphyseal bone architecture is often preserved while the articular surface is degenerate. In all these conditions the patient often presents for revision total elbow arthroplasty with relevant co-morbidities and relevant musculoskeletal dysfunction (for example ipsilateral shoulder, wrist, thumb or hand dysfunction). Infection is a universal concern for revision arthroplasty but where the soft tissue 'envelope' is compromised and already limited, as in the proximal forearm, it is difficult to eradicate, particularly in immunocompromised patients. Bone loss compromises subsequent implantation of a revision prosthesis, while failure to restore the working lengths of the humerus and ulna reduces the strength of the flexor and extensor compartment muscles for elbow motion. Failure to restore the continuity of the triceps aponeurosis - antebrachial fascia and triceps medial head-olecranon components of the extensor 'mechanism' also compromises extensor power. Prior triceps-dividing surgical approaches will determine the elasticity, and therefore pliability, of the extensor 'mechanism' this will have a role in determining how much gain in length of the humeral side can be safely achieved. The ulnar nerve, and its management during elbow arthroplasty, is a source of frequent concern, particularly for revision of an elbow arthroplasty undertaken for distal non-reconstructable humeral articular fractures or post-traumatic arthropathy, in which the position of the ulnar nerve is never anatomic. For these reasons revision total elbow replacement (RTER) is challenging it requires experience with surgical exposures of the elbow including the major nerve trunks, familiarity with the restoration of bone stock, a range of prostheses and techniques for prosthetic implantation, the ability to achieve adequate soft tissue cover and primary closure, and a logical approach to individualised rehabilitation.