Revision total elbow arthroplasty with the linked Coonrad-Morrey total elbow arthroplasty: a retrospective study of twenty procedures

Purpose

In this retrospective study we evaluated the short- to medium-term results after 20 Coonrad-Morrey revision total elbow arthroplasties (TEAs).

Methods

We included a consecutive series of revision TEAs performed at our institution from 2004 to 2010. At a mean follow-up of 4.4 years, patients were evaluated using the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES) and standard radiographs.

Results

The mean age at revision TEA was 65.8 years. The median time of implant survival for primary prosthesis was 9.5 years. The mean post-operative MEPS was 79. The mean OES was 58, 66 and 53 for function, pain and social-psychological dimensions, respectively. At follow-up the range of motion had improved significantly. There were two cases of radiolucent lines and two cases of minor bushing wear; however, none of the implants were clinically loose. In one case deep infection led to a further revision. Two patients had post-operative ulnar nerve paraesthesia.

Conclusions

Results after revision TEA using the Coonrad-Morrey prosthesis are acceptable with a low short- to midterm failure rate. Revision improves range of motion and provides pain relief. One case of deep infection with recurrent revision is of concern. The treatment can be used as an option for failed TEA.     

Revision total elbow arthroplasty

Over a ten-year period, thirty-three consecutive revision total elbow arthroplasties were performed at our institution. These were assessed at a minimum of three years after the revision, with an average length of follow-up of sixty-one months. Eighteen (55 per cent) of the elbows had a good result and fifteen (45 per cent) had a poor result. The poor results were due to infection in three elbows, loosening of the prosthesis in six, inadequate motion in two, continued pain in two, and prosthetic failure in two. Additional surgical revision with another implant was done in the fifteen elbows that initially had a poor result. Eventually the result was good in twenty-four elbows. The three elbows that became infected after surgical revision had a resection arthroplasty and all were rated as having a fair result. The data from this study indicated that reimplantation is a viable option for the revision of a failed total elbow arthroplasty, although more than one revision may be required. They also suggested that young patients who have post-traumatic arthritis should not undergo a total joint replacement, and that revision procedures should be performed in settings that can offer several surgical options and by surgeons who have had experience with these options. Alternatives to reimplantation as a revision procedure should be considered in selected patients.     

Revision of failed total hip arthroplasty

Ninety-seven revisions of total hip replacements are reviewed with a median time of observation of 47 months. Satisfactory pain relief was obtained in 86%. There were six complete failures which were reduced to three by further surgery. One hip became infected and was excised. In 12 cases the revisions were complicated by peroperative fractures and in five by dislocations. Radiographic analysis disclosed a high percentage of periarticular ossification and 25 cases of radiographic loosening of the femoral implant.     

Revision of a failed patellofemoral arthroplasty to a total knee arthroplasty

BACKGROUND: Patellofemoral arthroplasty is an effective treatment for isolated arthritis of the anterior compartment of the knee, but it is unclear whether it compromises the results of total knee arthroplasty if revision is necessary. The purpose of this study was to review the results of total knee arthroplasty after a prior patellofemoral arthroplasty. METHODS: Twelve failed patellofemoral replacements in ten patients were revised to total knee arthroplasties for isolated progressive tibiofemoral arthritis (six knees), isolated patellofemoral catching and maltracking (three), or a combination of both (three). Revisions were performed at a mean of four years after the patellofemoral arthroplasty. A posterior stabilized implant was used in each knee, without a need for stems, augments, or structural bone graft. Patients were assessed by clinical and radiographic follow-up, including Knee Society clinical and functional scores. Baseline preoperative Knee Society scores were obtained at the time of evaluation of the failed patellofemoral arthroplasty. RESULTS: At a mean follow-up of 3.1 years, the mean Knee Society clinical and functional scores had increased from 57 points preoperatively to 96 points and from 51 points preoperatively to 91 points, respectively. At the most recent follow-up, there was no clinical or radiographic evidence of patellofemoral maltracking, loosening, or wear. CONCLUSIONS: On the basis of our experience in this relatively small series with short-term follow-up, the results of total knee arthroplasty do not seem to be compromised after revision of the failed patellofemoral replacement.     

Revision total elbow arthroplasty for prosthetic fractures

BACKGROUND: Fractures of total elbow arthroplasty components are uncommon, and the literature provides little guidance regarding the management and outcomes of treatment of these complications. The goal of this report was to investigate the prevalence and management of fractures of ulnar and humeral components following total elbow arthroplasty and to review our experience with cement-within-cement reconstruction for revision following such fractures. METHODS: Between 1979 and 2003, twenty-four patients with a total of twenty-seven fractured total elbow arthroplasty components (seventeen ulnar and ten humeral) of different designs presented to our institution. Twenty-six implants underwent subsequent revision elbow arthroplasty at our institution. Fourteen of those revisions were done with a cement-within-cement technique, and twelve, with traditional methods. Twenty-one patients (twenty-three implants) were available for final follow-up, and data that had been acquired prospectively and entered into the institutional arthroplasty database were reviewed retrospectively. At the time of final follow-up, the Mayo Elbow Performance Score (MEPS) was calculated and preoperative, postoperative, and most recent radiographs were examined for bone loss, bushing wear, and integrity of the bone-cement interface. RESULTS: The prevalences of humeral and ulnar component fracture following primary total elbow arthroplasties performed at our institution were 0.65% and 1.2%, respectively. At a mean of 5.1 years following revisions for those fractures, the MEPS was excellent for eight patients, good for five, fair for six, and poor for two. The average MEPS was 82 points following the revision total elbow arthroplasties done with the cement-within-cement technique and 78 points following the revisions done with the traditional method of cement removal and insertion of a revision component. Complications included seven intraoperative cortical perforations; five nerve injuries, two of which were permanent; three triceps avulsions; and one deep infection. CONCLUSIONS: Implant fractures following total elbow arthroplasty are uncommon. They occur for several reasons, such as notch sensitivity, component design, and high stresses due to bone deficiency. Revision techniques, such as cement-within-cement reimplantation, are reliable for relieving pain and restoring function; however, the rate and spectrum of complications are a cause for concern. LEVEL OF EVIDENCE: Therapeutic Level IV.     

Results of reconstruction for failed total elbow arthroplasty

Failure of total elbow arthroplasty leads to difficult and complicated surgical reconstruction. This study evaluates the results of reconstruction after implant removal with respect to pain, motion, and functional ability. Between 1978 and 1985, 11 patients required implant removal. Indications for removal were infection for seven, implant fracture for three, and recurrent dislocation for one. The original diagnosis was rheumatoid arthritis in six elbows and traumatic arthritis in five. The average length of the follow-up period was 5.5 years after implant removal (minimum, two years). Treatment consisted of implant removal and soft-tissue arthroplasty combined with external fixation in ten patients, and attempted arthrodesis with external fixation in one. There were four good, one fair, two poor, and four failed results. Satisfactory results were obtained in seven of the eight elbows in which an anatomic arthroplasty was achieved. This consisted of containment of the ulna by the humeral epicondylar remnants. All eight elbows were pain-free with an average arc of motion of 85 degrees (range, 55 degrees to 120 degrees). They had excellent elbow flexion power; however, triceps strength was often compromised. In the three elbows in which anatomic arthroplasty could not be achieved, one was flail, one was later converted to an arthrodesis with a customized plate, and the third required an immediate arthrodesis. All three were rated as failures. Fractures occurred in five of the 11 elbows. One occurred preoperatively, three occurred intraoperatively, and one occurred postoperatively. All healed satisfactorily during the course of immobilization. The importance of an anatomic arthroplasty when removing a total arthroplasty cannot be overemphasized. Retaining the epicondylar segments is important because satisfactory results were obtained in patients in whom entrapment of the olecranon within the epicondylar ridges was obtained. Such patients can achieve a satisfactory soft-tissue arthroplasty without the use of an interpositional material. When the epicondylar ridges were not retained and there was marked instability, the patients did not achieve satisfactory results.     

Revision arthroplasty with use of a total femur prosthesis

BACKGROUND: Surgeons performing revision arthroplasties of the hip and knee are confronted with a growing number of patients with extensive loss of bone stock. Implantation of a total femur prosthesis is a possible method of treatment of such patients. The purpose of this study was to assess the functional outcomes and the complications associated with total femur replacements used in revision arthroplasty. METHODS: We evaluated the results associated with 100 total femur prostheses that had been implanted during revision arthroplasty in 100 consecutive patients without infection. The mean duration of follow-up was five years. The prosthesis was implanted because of a complication of a total hip replacement in seventy-seven patients, because of a complication of a total knee replacement in four, and because of a complication affecting the diaphysis of the femur in nineteen. Thirty-nine patients had sustained a periprosthetic fracture, usually in combination with loosening of the prosthesis, before the revision. The radiographs made at the time of the latest follow-up were evaluated for signs of loosening and material failure. The preoperative and postoperative function of the hip and knee was assessed according to the Enneking score. Five patients were lost to follow-up. RESULTS: Sixty-five patients (68%) had no complications. Deep infection was found in twelve patients (13%); dislocation, in six (6%); material failure, in three (3%); patellar problems, in two (2%); and peroneal nerve palsy, in one (1%). The mean preoperative Enneking score for hip function was 1.25 points, and it improved to 3.29 points postoperatively. The mean Enneking score for knee function was 2.09 points preoperatively and 3.29 points postoperatively. CONCLUSIONS: We believe that the total femur prosthesis is a useful implant for patients with extensive bone loss at revision arthroplasty. While the infection rate was high, the overall functional results for both the hip and the knee were rated as better than good with the Enneking classification.     

Revision total knee arthroplasty for failed unicompartmental replacement

The results in nineteen patients (twenty-one knees) who had a failed unicompartmental knee replacement followed by a revision total knee arthroplasty were evaluated. There were twelve excellent, four good, one fair, and two poor results. The interval between the unicompartmental replacement and the revision total knee arthroplasty ranged from eight months to eight years. At the time of the revision, a major osseous defect was found in sixteen knees (76 per cent). The duration of follow-up after the revision ranged from two to ten years. At the most recent follow-up examination, radiographs revealed at least one radiolucent line in thirteen knees (62 per cent). The technical difficulties associated with the revision operation are evidence that unicondylar arthroplasty is not a conservative procedure that allows a total knee arthroplasty to be done easily later. The results also do not support the argument that a revision performed after failure of a unicondylar arthroplasty is less technically demanding than one performed after a failed primary total knee arthroplasty.     

人工股骨头置换术后全髋关节翻修术的临床研究

目的探讨人工股骨头置换术后全髋关节翻修术的手术指征和技巧。方法回顾性分析1997年6月至2000年6月行人工股骨头置换术后全髋关节翻修术的56例患者的临床资料。其中男性31例,女性25例;年龄64—75岁,平均68岁。翻修原因中,人工股骨头置换术后髋臼磨损29例（51．8％）,髋臼磨损及股骨头中心性脱位14例（25．0％）,股骨柄松动12例（21．4％）,股骨柄断裂1例（1．8％）。Harris评分术前平均37分（28～40分）。所有病例均一期翻修,有骨质缺损者同时植骨。结果49例患者术后获得平均7年（5—8年）随访,7例失访。末次随访Harris评分平均88分（84～90分）。全部病例术后无伤口感染和神经血管损伤。5例患者出现并发症,其中扩髓时骨皮质不全骨折1例,术后下肢深静脉血栓3例,髋关节脱位1例。随访患者中无髋臼及股骨柄假体需要再度翻修。X线片显示人工关节假体位置正常,无松动感染征象。结论髋臼磨损及股骨头中心性脱位是人工股骨头置换术后全髋关节翻修的主要原因。中期临床随访结果显示,若手术指征正确,手术技巧娴熟,该翻修手术可以获得良好的临床效果。     

Radiohumeral arthrodesis for salvage of failed total elbow arthroplasty

Ulnohumeral arthrodesis is the standard technique for elbow fusion. The geometry and surface area of the distal humerus and proximal ulna enhance the chances of fusion while maintaining some wrist motion. A case of a patient with multiple failed elbow procedures in which the standard ulnohumeral fusion was not possible is presented. A radiohumeral arthrodesis was performed in an attempt to obtain a stable, nonpainful elbow. After complete healing of the fusion, the patient was able to use the arm for most functions. This technique is presented as an option for salvage failed elbow arthroplasty in the face of significant bone loss.     

Results of total elbow arthroplasty as a salvage procedure for failed elbow reconstructive operations

Total elbow arthroplasty (TEA) was used as a salvage procedure following failed open reduction and internation fixation, failed triaxial arthroplasties, and septic and aseptic loosening of implant arthroplasty. A minimally constrained bicondylar implant with a block to disarticulation was substituted for the reconstruction of 20 revision TEAs. Custom-designed implant TEA was substituted in cases with substantial bony or soft tissue loss. Revision of the polyethylene-bearing component, coupled with the addition of a yolk-type locking mechanism, was implanted when only the bearing system of a well-fixed implant had failed. TEA can be performed successfully with satisfactory durability as a revision procedure. Revision of failed open reduction internal fixation or a failed bearing system was highly successful. Revision of previously infected elbows in a single-stage procedure was unsuccessful in two of three cases and has been abandoned in favor of a staged procedure. A revision of loose TEA was successful in only three of five cases. Further investigations are necessary to improve the function durability of TEA.     

Revision of failed total hip arthroplasty with a proximal femoral modular cemented stem

We have designed a modular cemented femoral component for revision of failed total hip arthroplasty in which deficiency of the proximal femur is such as to require a variable extrafemoral portion of the stem. We present the results of the first 74 operations in 72 patients; 56 of the patients had grade-3 or grade-4 femoral deficiency as defined by Gustilo and Pasternak and 24 had fractures of the proximal femur, of which 22 were periprosthetic. There was or had been infection in 19 hips. At a mean follow-up of 5 years 9 months (1 to 12 years) nine stems were radiologically loose of which three had been revised. There were no failures in 45 cases in which there was fixation of the distal stem of 10 cm or more. Dislocation occurred in nine patients and there were four cases of infection in the 19 which were, or had been, infected previously. There were no neurovascular complications and no intraoperative femoral fractures. The femoral bone stock improved radiologically in 45 hips of which 29 showed considerable reformation of the proximal femur; 27 remained unchanged and two showed increasing osteoporosis.     

Revision total elbow arthroplasty with impaction allografting and uncemented partially hydroxyapatite-coated custom-made prostheses

Total elbow arthroplasty has become a relatively common procedure in the last decade, and the number of primary total elbow replacements performed is likely to continue to increase as the population ages. The incidence of technically demanding prosthesis revisions involving complex problems such as major bone loss is therefore expected to increase. We report 3 cases of total elbow revision arthroplasty, all of which represented patients with severe bone loss. They were all treated using the impaction allografting technique and uncemented custom-made semiconstrained prostheses partially coated with hydroxyapatite manufactured at the bioengineering department of our institution.