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 allows 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

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

Of 81 elbow replacements performed over a seven-year period, 11 were total elbow revision (TER) procedures, which were done on two men and nine women with a mean age of 61 years (40 to 70). Seven of the patients had rheumatoid arthritis, three had post-traumatic osteoarthritis and one had haemophilia. The reason for revision was aseptic loosening in eight patients and aseptic loosening with fracture in the other three. The prostheses revised were the Souter in eight patients, the Kudo in one, the GSB I in one and the Dee in one. In revision TER, one long stem Souter prosthesis was used, two Pretoria, one GSB 3 and seven Morrey. The mean time from primary to revision TER was 10 years (2 to 31).

At a mean follow-up of 30 months (6 to 48), all except one patient were pain-free and the arc of flexion had increased by 30°. Complications included one dislocation, one radial nerve palsy, which recovered after six months, and one aseptic loosening. There were no cases of sepsis.

Revision TER is a technically demanding procedure with a high risk of complications. In this series patient satisfaction was high. Our policy is to use a hinged prosthesis, preferably the Morrey, in revision TER.

A 55-year-old woman who was diagnosed as RA (stage, class ) in 1995 had undergone right total elbow arthroplasty (TEA) in October 2006. We implanted her prosthesis FINE ELBOW^® (Nakashima Medical, Japan). Prosthesis of the humerus side is made of Co-Cr-Mo, and the ulna side is of polyethylene. Radius side is metal back system which inserts a polyethylene joint part in metal holder made by Co-Cr-Mo. All components were fixed by cement. She complained her right elbow uncomfortable gradually from January 2008. X-ray radiograph showed loosening of the ulnar component.

So we performed revision surgery using ulnar revision sack in May 2008. This ulnar component had only a product made in polyethylene and we inserted the component of the product made in the polyethylene in a metal sack. The operation was successed and now she does housework.

We think that strength is not worthy of the ulnar component made by polyethylene in TEA for the patient with terrible joint destruction and high daily activity patient of rheumatoid arthritis.

At our institution between 1994 and 2003 a total of 36 revision total elbow Arthroplasties were performed in 34 patients. We clinically reviewed 25 patients and reviewed the notes and x-rays of all of them. Of eleven who were not reviewed clinically seven had died from an unrelated cause and four were unable to attend because of illness but we were able to include them as sufficient data were available in the notes. There were 24 female and 12 male, Average age was 67 years and twelve had elbow Arthroplasty in a non-dominant side. The average follow up was 6 years (range 5–13 years). The mean period between the primary and revision surgery was sixty three months (range 3–240 months). The indication for surgery was mainly for aseptic loosening in 15 cases, followed by septic loosening in twelve. All cases of septic loosening had two stage revisions. Other reasons for revision in this series include unstable elbows, implant fracture and peri-prosthetic fractures. Twelve of these revisions had a further revision for a variety of reasons at an average period of twenty eight months. Seven patients had thirteen complications in this series, two radial nerve palsies (one recovered), one distal humeral fracture, five cortical perforations and five triceps weakness. Most of the patients are satisfied with their elbows. The mean Mayo elbow Performance Score was 79 points. We conclude that revision Elbow Arthroplasty is a specialized surgery which is technically demanding, with high risk of complications and high re-revision rate and therefore, should be done in a specialised centres.

The purpose of this study is to report our experience with revision of total elbow arthroplasty by exchange cementation. Between 1982 and 2004 at our institution, forty six elbows were treated with exchange cementation of a total elbow arthroplasty into the existing cement mantle or debrided bone interface, without the use of an osteotomy, bone graft or prosthetic augmentation. Indications for the procedure were aseptic loosening (17), second stage after septic loosening (14), instability (7), prosthetic fracture (4), periprosthetic fracture (2), failed hemiarthroplasty (1) and ulnar component wear (1). Both components were exchanged in 18 elbows, the humerus alone in 25 and the ulna in 3. Mean follow up was 90.5 months (10 to 266 months);18 patients had died with the prosthesis in situ. Complications were noted in 22 elbows; periprosthetic fracture of ulna (6) and humerus (2), humeral component fracture (1), aseptic loosening (4), non-union (1), heterotrophic ossification (2), soft tissue contracture (2) and soft tissue failure (2), delayed wound healing (1) and bushing failure (1). Reoperation was required in 10 elbows for revision of both components (2), ulna (3), humerus (1), bushing revision (2), soft tissue debridement (1) and soft tissue repair (1). There were no septic recurrences in previously infected elbows; however the reoperation rate in this group was 29% versus 19% after re-cementation for other causes. Revision of total elbow arthroplasty by exchange cementation is a reasonable treatment for those elbows with adequate bone stock for secure prosthetic fixation; however careful consideration should be given to augmentation of the ulna due to the high rate of periprosthetic fracture in this series. Re-cementation following débridement for infection is effective despite having a higher rate of revision operation compared to re-cementation in the aseptic elbow

Thermal injury to the radial nerve caused by cement leakage is a rare complication after revision elbow arthroplasty. Several reports have described nerve palsy caused by cement leakage after hip arthroplasty. However, little information is available regarding whether radial nerve injury due to cement leakage after humeral stem revision will recover. In a recent study, radial nerve palsy occurred in 2 of 7 patients who had thermal injury from leaked cement during humeral component revisions. These patients did not regain function of the radial nerve after observation. We present a case of functional recovery from a radial nerve palsy caused by cement leakage after immediate nerve decompression in revision elbow arthroplasty[Fig. 1.2].

Aims. The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry. Methods. All TEAs recorded in the Dutch national registry between 2014 and 2020 were included. The Kaplan-Meier method was used for survival analysis, and a logistic regression model was used to assess the factors associated with revision. Results. A total of 514 TEAs were included, of which 35 were revised. The five-year implant survival was 91%. Male sex, a higher BMI, and previous surgery to the same elbow showed a statistically significant association with revision (p < 0.036). Of the 35 revised implants, ten (29%) underwent a second revision. Conclusion. This study reports a five-year implant survival of TEA of 91%. Patient factors associated with revision are defined and can be used to optimize informed consent and shared decision-making. There was a high rate of secondary revisions. Cite this article: Bone Jt Open 2023;4(2):110–119

Summary Statement. Discovery system produced effective functional improvement in both primary and revision total elbow replacement. The incidence of major complications was in an acceptable range. Introduction. The search for the ideal elbow prosthesis continues as instability and loosening remain the prime reasons for total elbow replacement (TER) failure. The Discovery Elbow System (Biomet) is one of the latest generations of linked prosthesis and has been used in UK since 2003. We report outcome of TER using this system. Methods. A total of 100 TERs (75 primary, 25 revisions) were performed between 2003 and 2010. The main primary underlying pathologies for TER were advanced rheumatoid arthritis (N=58), osteoarthritis (N=35), acute fractures (N=7). There were 60 female and 40 male patients with an average age of 62 years. The outcome assessment included pain, patient satisfaction, Liverpool Elbow Score (LES), range of movement, and imaging during a mean follow-up period of 48.5 months. Major complications are also reported. Results. For the whole patient group (primary + revision), the LES was significantly (p<0.001) improved from 3.79+/−1.71 to 6.36+/−1.85There were significant improvements in elbow flexion from 100°+/−24 to 118°+17, supination from 38°+/−26 to 50°+/−25 and pronation from 48°+/−22 to 61°+/−21. Mean improvement in flexion-extension and pronation-supination arc was 20° and 25°, respectively. 64% of cases were completely pain-free and at the final follow-up (compared to 7% preoperatively). Only 6% of patients scored “Not Satisfied” at the final follow-up. LES improvement was significantly higher in the primary TER compared to revision TER (p<0.05). Imaging reviewed for 60 cases showed loosening in 4% of patients. Other main complications included deep infection (N=2), ulnar neuropathy (N=3), pre-prosthetic fracture (N=2), and prosthetic failure (N=1). Discussion. TER using the Discovery Elbow System is an effective arthroplasty in terms of functional improvement, pain relief and range of motion in both primary and revision patients. TER resulted in no/mild pain in 78% of cases. Patients undergoing Acclaim, Souter-Strathclyde, GSB III, and Coonrad-Morrey TER have been reported to have no/mild pain in 64%, 67%, 50–92% and 60–100% of cases, respectively. A 20° improvement in flexion-extension arc is comparable to that of Acclaim (23°), Souter-Strathclyde (15°), GSBIII (19–33°), and Coonrad-Morrey (17–26°) TER. An improvement of 25° in pronation-supination arc in our series is also comparable to that of 21–28° reported the Coonrad-Morrey and 27–33° for Discovery prostheses. An infection rate of 2% is lower than several other reports for GSB III TER (7–11%) and Coonrad-Morrey (6–8%). The incidence of persistent ulnar neuropathy (3%) was lower compared to GSBIII TER (11–14%), Coonrad-Morrey (12–26%), and Acclaim (8%)

Reconstruction of deficient bone stock during total elbow arthroplasty in rheumatoid arthritis represents a challenge for the surgeon. Fracture and osteolysis of the olecranon process is a very rare condition in rheumatoid arthritis. The consequence of a deficient olecranon is an instable and painful elbow. We report a case of successful olecranon reconstruction with bone graft associated to total elbow arthroplasty with a 8 years follow up and discuss surgical aspects. This case concerns a 44 years old woman with a very severe rheumatoid arthritis. She complains of pain and instability of her right elbow. X-rays show fracture and major osteolysis of the olecranon process with only some persistent bone at the insertion of the triceps tendon. The humeral condyles were subluxated posteriorly. We performed a total elbow replacement with a GSB3 implant and reconstruction of the olecranon with two cancellous iliac bone strut fixed by 2.7 diameter screws to the proximal ulna. The triceps tendon with remnant olecranon bone chips was secured to the bone graft by tension band wiring. Postoperatively, the elbow was immobilized for 3 weeks. With a follow up of more than 8 years the elbow is pain free with excellent function. The active range of motion of flexion – extension is 140° / −20°. The elbow is stable and triceps function is very satisfying authorizing the use of crutches. X-rays show good bony integration of the reconstructed olecranon process and no signs of loosening of the GSB3 implant. The literature concerning olecranon reconstruction during total elbow arthroplasty in rheumatoid patients is very poor. Kamineni and Morrey reported on one case of olecranon reconstruction with strut allograft in revision total elbow arthroplasty with an unsatisfying result. Their fixation technique was different. We prefer an autograft whenever it is possible and we recommend our fixation technique using screws and tension band wiring

Purpose:. Interposition arthroplasty is a salvage procedure for patients with severe osteoarthritis of the elbow where conservative treatment failed. It is mostly performed in younger patients where total joint replacement is contraindicated and an arthrodesis is unattractive. Although one of the oldest reconstructive options for elbow arthritis, the procedure is not without complications. There are only a few case series described in the literature. The purpose of our study is to review our cases and report their outcome. Method. We retrospectively reviewed 18 consecutive cases of interposition arthroplasty between 2001 and 2010. 2 cases were excluded due to incomplete records. The mean patient age was 41.3 (19.4–58.6) years at time of surgery. The primary diagnosis was post-traumatic osteoarthritis in 11 cases and inflammatory osteoarthritis in 5 cases. The mean follow up was 4.7 (0.4–10) years. Pre- and post-operative pain and function was evaluated using the Visual Analogue Scale (VAS) and Mayo Elbow Performance Score (MEPS). The complications and the number of re-operations and revisions were recorded. Summary of results:. In 12 (75%) cases at least one revision operation was performed, because of sepsis, ulnar nerve symptoms, instability and unsatisfactory clinical results. Sepsis rate was 25%. In 7 cases there was an unsatisfactory clinical result (i.e. ongoing pain and poor function), resulting in revision by total elbow replacement in 4 cases, arthrodesis in 2 cases and a re-do interposition in 1 case. The mean interval from the interposition to revision procedure was 2.6 (0.6–7.4) years. In 9 patients with the interposition currently in situ, mean VAS improved from 7.4 to 2.4 and mean MEPS from 42 (30–60) to 75 (40–100). Conclusion:. Interposition arthroplasty offered improvement in pain and function, but at a high cost. It is associated with a high rate of complications and need for revision surgery that we feel might be unacceptable

Background. The procedures of total elbow and shoulder replacements increased 6% to 13% annually from 1993 to 2007 with revision-related burden increasing from 4.5% to 7%. The revisions of the shoulder and elbow prostheses due to aseptic loosening, periprosthetic fractures, infections have led to the use of standard or custom-made implants due to significant bone loss. This study reports our experience in the management of complicated primary and revisions of total shoulder and elbow replacements with significant humeral bone loss and in metabolic diseases of the elbow and shoulder treated with bone resection using The Mosaic Humeral Replacement System. Patients and Materials. A total of 20 patients underwent total elbow or shoulder arthroplasty using the Mosaic Humeral Replacement System (Biomet, UK). The Mosaic system was used in 8 shoulder arthroplasties (Group A) and in 12 elbow arthroplasties (Group B). The underlying pathologis in Group A included 2 malunited proximal humerus fracture, 1 humeral osteomyelitis, 1 shoulder chondrosarcoma, 1 aggressive Gigantic Cell Tumor with prosthetic fracture, 2 metastatic lytic lesion, and 1 failed fixation of non-union proximal humerus. Figure 1 shows Mosaic implant after complex fracture of proximal humerus. Reasons for Mosaic arthroplasty in Group B included 3 humeral component revisions due to periprosthetic fracture, 1 prosthesis breaking-up with fractures, 1 revision of loose Souter Strathclyde prosthesis, 1 loose prosthesis due to infection, 1 highly comminuted elbow fracture, 1 aseptic loosening of humeral component of total elbow replacement, 3 revision of total elbow replacement due loosening and 1 pathological distal humerus fracture due to metastasis. Figure 2&3 shows pre- and post-operative Mosaic implant following complex periprosthetic fracture of distal humerus. Clinical Observation/Discussion. The Mosaic Humeral Replacement System is a complete system for complex revision, salvage/oncology, and complex humeral fractures. It is a completely modular system which can be adapted to different patient anatomies and indications. It has been designed to face several surgical challenges, including reattaching soft tissues, properly tensioning the glenohumeral joint and restoring joint function. It is a cost-effective procedure with the benefits of a custom made humeral component in a standard tray. Our study shows that good results can be achieved with this form of treatment. Radiological assessment of all patients showed a satisfactory position of the implant with appropriate margin of bony resection. One patient with proximal and another one with distal humeral Mosaic replacement had late infection. One patient had aseptic loosening 3 years after distal humeral replacement. Most of the patients had satisfactory improvement in range of movement and chronic pain. While primary clinical observations and imaging results indicate acceptable results with Mosaic arthroplasty; a realistic assessment can only be achieved in long-term using the appropriate outcome measures. At the present we continue to regularly assess the patients clinically and radiologically and by means of Liverpool elbow score for distal and Quick- DASH for proximal Mosaic Humeral Replacement System and plan to report the long-term results in due time