REVISION TOTAL ELBOW REPLACEMENT: A RATIONALE FOR TREATMENT

Abstract

Although it is generally accepted that revision total elbow replacement may be necessary for loosening, instability, peri-prosthetic fracture and infection there is less agreement as to whether surgery should be performed as a one or two stage procedure. This can be of vital importance since the soft tissues around the elbow are often relatively poor making a single operation desirable. However, a one stage procedure in the presence of undetected low grade infection will result in joint failure with early loosening.

In our unit we have found the use of a preliminary aspiration/drill biopsy prior to revision surgery helpful in evaluating whether a one or two stage procedure should be performed.

Over an 8 year period 18 revision total elbow replacements have been undertaken. 9 patients were revised for aseptic loosening, 4 for proven infection, 3 for instability of an unlinked implant and 2 for peri-prosthetic fracture.

With this experience we have devised the following management plan.

Early instability of an unlinked implant is due to either poor implant positioning or soft tissue balancing and is suitable for a one stage revision without the need for aspiration/drill biopsy. Late instability is due to implant wear or low grade infection. In this situation we regard an aspiration/drill biopsy as necessary. A negative result allow a one stage revision whereas a positive aspiration indicates the need for a two stage revision.

In a peri-prosthetic fracture if the bone cement mantle is intact a one stage revision without aspiration/ drill biopsy can be performed. If, however, there is bone cement lucency we would advise an aspiration/ drill biopsy.

We have found the aspiration/drill biopsy helpful prior to revision total elbow replacement and we have used it to guide us as to whether a one or two stage procedure should be performed.