This retrospective review was of 12 patients who had undergone a revision total elbow arthroplasty with impaction grafting between 1993 and 1997. There were 4 men and 8 women with an average age of 57 years (range, 37 to 80 years). Three of the patients underwent the impaction grafting during the initial revision procedure and the remaining 9 patients had undergone at least 1 prior revision. Seven patients had rheumatoid arthritis and 5 had post-traumatic arthritis. The indication for revision arthroplasty was aseptic loosening in all 12 patients. Ten patients presented with pain and 1 had a periprosthetic fracture. Two elbows were painless. In all cases, the bushings were exchanged. Two patients underwent impaction grafting in both the humerus and ulna; 4 patients in the ulna only; and 6 patients in the humerus only. Two patients had additional allograft strut grafts placed on both the ulna and the humerus to span structural defects. Two patients had allograft strut grafts placed only on the ulna and 1 patient had strut grafts placed only on the humerus.
The Coonrad-Morrey prosthesis was utilized in 10 patients and a custom prosthesis in two. The operative technique included identifying the ulnar nerve in all patients and exposing the elbow via a triceps-reflecting approach. Subperiosteal exposure was performed of the entire length of the ulna past the tip of the implant. All loose bone cement was removed. The radial nerve was also identified during revision of the humeral component. Strut grafts were then placed and secured with cerclage wires. A canal plug was placed and allograft was processed in a bone mill to obtain a uniform consistency of finely morselized bone. Two different techniques of impaction grafting were utilized. In the first technique, a double tube apparatus was assembled for the allograft bone to be placed around the outer tube and subsequently the inner tube was used to place the cement. In the second technique, a neomedullary canal was developed by sequentially packing in morselized cancellous allograft using appropriately sized punches, tamps and prosthetic trials. The final prosthesis was also used as an impactor. The neomedullary canal was then filled with cement via an injection gun.
All patients were examined clinically at a minimum of 2 years after implantation with impaction grafting. Radiographic evaluation was performed at a mean of 58 months (range, 25 to 84 months) after the operation. The index revision implant was functioning at the time of follow up in 8 of the 12 patients who had undergone impaction grafting. The average preoperative Mayo Elbow Performance Score was 55 points (range, 20 and 85 points) and the average postoperative score was 83 points (range, 55 to 100 points). The average arc of motion preoperatively was 86 degrees compared to 99 degrees after final follow-up. Six of the 12 patients had a functional arc of motion from at least 30 degrees of extension to 130 degrees of flexion. Six patients exhibited no evidence of radiolucent lines, 4 patients exhibited an incomplete line of 1 to 2 mm in width and 4 patients exhibited an incomplete line of greater than 2 mm in width. Six of the 12 patients had complications that required surgery including one that underwent a resection arthroplasty because of a deep infection 2 years following implantation. One patient underwent a repeat revision impaction grafting of both components. Another patient required repair of a ruptured triceps as well as a periprosthetic fracture distal to the tip of the ulnar component. Two patients underwent impaction grafting of the ulnar component that had previously had the humeral component performed.
Impaction grafting has been extensively utilized for revision hip arthroplasty. The technique is designed to restore bone stock and enhance the bone-cement interface. Despite the high complication rate, which has previously been documented for revision total elbow arthroplasty alone, 10 of the 14 components treated with impaction grafting were still in place without clinical signs of loosening. This method may be beneficial for patients requiring revision arthroplasty with substantial osteolysis around the total elbow prosthesis to help reestablish bone stock. It was utilized in this study for the most part with a standard prosthesis.
Journal of Bone and Joint Surgery