Reimplantation of a Total Elbow Prosthesis Following Resection Arthroplasty for Infection

Author(s): Cheung EV, Adams RA, Morrey BF

Source: J  Bone and Joint Surg 90-A (3) 589-594, 2008.

Summary:

This is a retrospective review of 29 patients treated between 1976 and 2003 with reimplantation of a total elbow prosthesis after a prior resection arthroplasty for a deep periprosthetic infection.  The mean time interval between primary total elbow arthroplasty to resection arthroplasty was 123 weeks (range, 7 to 365 weeks), and from resection arthroplasty to reimplantation  73 weeks (range, 8 to 707 weeks), and from reimplantation to last follow up of 7.4 years (range, 2.2 to 28.6 years).  Most patients received intravenous antibiotics for a mean duration of 42 days prior to reimplantation.  The mean total Mayo Elbow Performance Score (MEPS) was 36 points before reimplantation and statistically improved to a mean MEPS of 66 points post reimplantation.  At final follow-up, 15 elbows (51%) were rated as good to excellent.  Eleven elbows (38%) were rated as poor with 8 of  the 11 elbows considered treatment failures because of infection recurrence requiring repeat resection arthroplasty at a mean of 22 months (range, 1 to 72 months) postoperatively.  The most common infecting organism taken at the time of resection arthroplasty was staphylococcus epidermidis which was present in 13 (45%) of the 29 elbows, followed by methicillin-sensitive Staphylococcus aureus (7) and Klebsiella pneumonia (2).  There were 3 complications in addition to the 8 recurrences of infection which included 2 periprosthetic ulnar fractures and 1 periprosthetic humeral fracture with an associated radial nerve palsy. 

The authors report that reimplantation of a total elbow prosthesis after prior resection arthroplasty for treatment of infection is a reasonable option in patients dissatisfied with a resection arthroplasty.  However, upwards of 30% recurrence of infection can be expected resulting in multiple subsequent operations.  The authors suggest ways to optimize the chance of eradicating subsequent infections including vigilance with soft tissue handling, meticulous debridement at the time of resection arthroplasty of cement remnants and early consultation with infectious disease specialists as well as consideration for long-term oral antibiotic suppression especially for Staphylococcus epidermidis.  They also recommended prior to reimplantation to ensure normalized CBC with differential, ESR, and C-reactive protein levels as well as aspiration of the elbow with a cell count and culture to confirm absence of active infection.  In addition, they performed intraoperative tissue frozen-section analysis to confirm the absence of acute inflammation prior to cementing in a new prosthesis.  This study was over a 27 year span and therefore lacked a consistent treatment algorithm, was retrospective and involved a small number of patients.