Antibiotic treatment and timing of reimplantation

Antibiotic Holiday in 2-Stage Exchange for Periprosthetic Joint Infection: A Scoping Review

BACKGROUND

The use of a 2-stage exchange remains a common management strategy for periprosthetic joint infection (PJI). The use of an "antibiotic holiday" before the second stage to confirm the clearance of infection is often employed, but there is little evidence to guide this practice. The aim of this review was to systematically map the literature reporting on the use of an antibiotic holiday as part of a 2-stage revision for chronic PJI and to answer the question: is there a role for an antibiotic holiday in patients undergoing 2-stage exchange arthroplasty for PJI?

METHODS

Given the heterogeneity of the literature on this topic, a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant scoping review was conducted. Two reviewers developed and refined the search strategy and study eligibility criteria and pilot-tested the data charting form prior to data extraction. Data were analyzed descriptively.

RESULTS

Three databases were screened, with 504 full-text articles retrieved for review after screening 2,579 titles and abstracts. Of these, 243 were included for data charting. Most studies (238 of 243; 97.9%) were case series, and the remaining 5 (2.1%) were cohort studies that incorporated a direct comparison between continuous therapy and an antibiotic holiday. Most case series (202 of 238; 84.9%) utilized an antibiotic holiday. The proportion of patients who experienced treatment failure in the continuous therapy group (271 of 2,074 patients; 13.1%) was lower than that in the antibiotic holiday group (2,843 of 17,329 patients; 16.4%; p < 0.001). There was a greater proportion of studies with a between-stage interval of <3 months among case series utilizing continuous antibiotic therapy (66.7%) compared with those utilizing an antibiotic holiday (27.2%; p < 0.001).

CONCLUSIONS

There is no proven superiority of an antibiotic holiday during a 2-stage exchange to treat chronic PJI. Due to the need to extend the duration of the interval between the first and second stages in order to accommodate an antibiotic holiday, patients may be subjected to unnecessary prolongation of their treatment duration without an improvement in outcome.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Infection control rate in two-stage exchange for chronic periprosthetic joint infection: a retrospective cohort study focusing on antibiotic-free period

BACKGROUND

Limited information is available regarding the impact of antibiotic holidays on the infection control rate of two-stage revisions for chronic periprosthetic joint infection (PJI). This study aims to evaluate the impact of an antibiotic holiday on the infection control rate after two-stage exchange for PJI.

METHODS

We retrospectively analyzed data from patients with chronic PJI who underwent long-interval two-stage exchange using joint spacers at our center from June 2012 to June 2021. Patients were divided into Short Antibiotic Holiday (SAH, antibiotic holiday < 3 months) and Long Antibiotic Holiday (LAH, antibiotic holiday ≥ 3 months) groups. Following completion of the two-stage exchange treatment, patients were monitored for a minimum of 2 years to determine the infection control rate.

RESULTS

A total of 75 chronic PJI patients were included, comprising 42 hip and 33 knee cases. In chronic PJI of the hip, the LAH group demonstrated a significantly higher infection control rate compared to the SAH group (27/27 vs 12/15, p = 0.016). For chronic PJI of the knee, the infection control rate in the LAH group was comparable to that in the SAH group (20/21 vs 10/12, p = 0.238). Furthermore, no significant differences in clinical outcomes were observed between the LAH and SAH groups.

CONCLUSIONS

A ≥ 3-month antibiotic holiday, without compromising postoperative functional recovery, may enhance infection control rates after two-stage exchange for chronic hip PJI using joint spacers.

Effectiveness of two-stage revision with commercial polymethylmethacrylate articulated hip spacer: similar outcomes against monomicrobial and polymicrobial hip periprosthetic joint infections

Background: orthopaedic surgeons still struggle against a devastating complication - periprosthetic joint infection (PJI). A two-stage revision is considered the gold standard for chronic PJI for several authors, with success rates over 90 %. This strategy implies the remotion of the prosthesis and the implantation of an antibiotic-impregnated cement spacer in the joint. The primary objective of this study was to assess the effectiveness of a two-stage revision approach using a commercial prefabricated antibiotic-impregnated cement hip spacer for the treatment of hip PJI regarding monomicrobial and polymicrobial infections. Secondly, to assess risk factors for failure of two-stage revision. Material and methods: we conducted a retrospective study on patients that underwent revision of total hip arthroplasty (THA) between January 2002 and January 20218. We included adult patients with a diagnosis of chronic hip PJI that underwent two-stage revision using a prefabricated gentamicin-impregnated cement of polymethylmethacrylate (PMMA) hip spacer. We assessed whether it was monomicrobial or polymicrobial infections and comorbidities. Treatment success was defined when eradication of the infection was observed and no further procedures or mortality were registered after the second stage. Persistence or recurrence of infection was considered a failure of treatment. Results: the final series consisted of 84 patients treated with the same hip spacer: 60 (71.4 %) monomicrobial and 24 (28.6 %) polymicrobial joint infections with an overall follow-up of 59.0 (36.0-84.0) months. The overall success rate was 90.5 %. Eight (9.5 %) patients failed. Smoking and BMI greater than 30 m kg- 2 were identified independent risk factors for failure in multivariate analysis. Conclusion: our study suggests that prefabricated gentamicin-impregnated PMMA spacer is an effective tool for the treatment of PJI, achieving similar outcomes whether it is monomicrobial or polymicrobial infections. Randomized prospective studies are needed to obtain more reliable conclusions.

Influence of the Type of Bone Cement Used in Two-Stage Exchange Arthroplasty for Chronic Periarticular Joint Infection on the Spacer Replacement and Reinfection Rate

BACKGROUND

Antibiotic-loaded bone cement (ALBC) spacers are used in the first stage when treating periprosthetic joint infection (PJI). This study aimed to investigate whether a spacer made from commercial ALBC or plain bone cement with additional antibiotics could affect the spacer exchange rate before reimplantation.

METHODS

Patients undergoing two-stage exchange arthroplasty due to chronic PJI from January 2014 to August 2021 were retrospectively reviewed. The exclusion criteria included arthroplasty in the setting of septic arthritis, megaprosthesis, atypical pathogen infection, spacer placement unrelated to PJI, and spacer exchange due to mechanical complications. The patient demographics, brand of cement, and microbiology were recorded manually. The primary outcome was the incidence of spacer exchange due to persistent infection and the secondary outcome was the incidence of reinfection after reimplantation. A multivariate logistic regression analysis and Chi-square test were conducted to identify the effect of cement type on the spacer exchange.

RESULTS

A total of 334 patients underwent two-stage exchange arthroplasty for PJI. The spacer exchange rates in the commercial and non-commercial ALBC groups were 6.4% and 25.1%, respectively (p = 0.004). After controlling for confounding factors, there were significant differences between the commercial group and non-commercial groups in the spacer exchange rate (adjusted OR = 0.25; 95% CI = 0.72-0.87, p = 0.029). The use of commercial ALBC was not associated with a lower reinfection rate after reimplantation (p = 0.160).

CONCLUSIONS

In a two-stage exchange arthroplasty scenario, the spacer comprised of commercial ALBC resulted in a lower spacer exchange rate than the plain bone cement, both of which had additional antibiotics. However, the use of commercial ALBC was not associated with a lower incidence of reinfection following reimplantation.

Does Time to Reimplantation After Explant for Prosthetic Joint Infection Influence the Likelihood of Successful Outcomes at 2 Years?

BACKGROUND

Consensus recommendations are lacking regarding appropriate timing of reimplantation following 2-stage resection arthroplasty for prosthetic joint infections (PJIs). We investigated whether the time from resection arthroplasty to reimplantation was associated with treatment outcome at 2 years.

METHODS

Retrospective cohort review was conducted for 101 patients undergoing resection arthroplasty with an antibiotic spacer for PJI at a single tertiary academic referral institution. Time from explantation and spacer placement to reimplantation was categorized into 3 groups: <12, 12-18, and >18 weeks. Baseline patient and treatment course characteristics across these groups were obtained. Multivariate binary logistic regression was used to characterize association between treatment failure and time to reimplantation, controlling for American Society of Anesthesiologists (ASA) score and prior revision surgery.

RESULTS

Time to reimplantation (TTR) >18 weeks demonstrated statistically significant increased odds of treatment failure, after controlling for ASA score and prior revision surgery (odds ratio 7.00, confidence interval 2.14-25.42, P = .002). After excluding patients requiring second spacer or Girdlestone prior to replant, this increased odds of failure remained (odds ratio 4.12, confidence interval 1.18-15.37, P = .029). TTR groups were similar with respect to demographics, except for ASA (2.96 for time to reimplantation >18 weeks vs 2.55 for time to reimplantation <12 weeks; P = .011). Patients with TTR >18 weeks were more likely to have an unplanned readmission during the spacer period (48%, 19%, and 6% for time to reimplantation >18, 12-18, and 0-12 weeks, respectively; P < .002).

CONCLUSION

Although decision regarding TTR is largely patient specific, surgeons should be aware that TTR >18 weeks may be associated with higher rates of treatment failure at 2 years.

Role of bacterial colonisation of vancomycin-gentamicin spacers in two-stage arthroplasty revision surgery: the usefulness of spacer sonication

PURPOSE

In two-stage replacements for septic loosening, some studies have suggested an association between bacterial colonisation of spacers and a higher number of complications after implantation of the definitive prosthesis. Our study aimed to determine the reoperation rate of patients undergoing two-stage revision surgery according to the culture results of spacer sonication.

METHODS

A retrospective observational study was conducted in which hip or knee spacers implanted at our institution with a diagnosis of periprosthetic joint infection from 2010 to 2018 were analysed. Patients were grouped into three categories: A. Patients with positive spacer sonication fluid culture, with or without positive cultures of the rest of the samples. B. Patients with negative spacer sonication culture and negative cultures of the rest of intraoperative samples. C. Patients with negative spacer sonication culture but positive cultures of the rest of intraoperative samples.

RESULTS

A total of 45 spacers were analysed: 10 were included in group A, 24 in group B and 11 in group C. The reoperation rate during the first year after the 2-stage revision surgery was 20%, 29.2% and 54.5% for each group, respectively, due to an infection in 10%, 20.8% and 45.5%. Spacers were colonised in all cases by low virulent micro-organisms.

CONCLUSION

In our study, bacterial colonisation of the spacer is not associated with a higher rate of reoperation. The group of patients with positive intraoperative cultures during the second-stage had the highest reoperation rate.

Clinical Evaluation of Alpha Defensin Test Following Staged Treatment of Prosthetic Joint Infections

BACKGROUND

Diagnosing persistent infection following staged treatment of prosthetic joint infection (PJI) is challenging. The alpha defensin (AD) test has been shown to be an accurate diagnostic test for the primary diagnosis PJI but has limited evaluation for use following a staged treatment of PJI. The goal of this study was to evaluate the diagnostic accuracy of AD testing following staged treatment of PJI before reimplantation surgery and to determine if negative AD test predicted success following reimplantation using Delphi Criteria at time of last follow-up.

METHODS

Patients who underwent AD testing prior to reimplantation after staged treatment of PJI (n = 52) were reviewed. Preoperative data (AD result, synovial fluid [SF], C-reactive protein level [mg/L], SF culture, SF white blood cell count, % of polymorphonuclear lymphocytes, serum C-reactive protein/erythrocyte sedimentation rate) and intraoperative data (purulence and tissue culture) were reviewed and used to classify patients using 2018 Musculoskeletal Infectious Disease Society criteria for infection, which was then used as a gold standard test to calculate diagnostic accuracy. Chart review was used to determine if patients who underwent reimplantation surgery would go on to treatment failure as defined by Delphi Criteria.

RESULTS

The sensitivity and specificity of AD test result as compared with Musculoskeletal Infectious Disease Society criteria in diagnosing PJI was calculated to be 71% and 97.78%. Positive predictive value was calculated to be 83.3%, and negative predictive value was calculated to be 95.65%. Patients who underwent reimplantation (46/52 patients) all had negative AD test results, and 9/46 or 19.5% would have treatment failure as defined by the Delphi Criteria with an average follow-up of 588 days.

CONCLUSION

AD demonstrates high specificity and negative predictive value, with low sensitivity when utilized after staged treatment of PJI. Further investigation of this and other diagnostic tests following staged treatment of PJI is needed. Additionally, validated criteria used to identify persistent infection following staged treatment of PJI are required.

Risk Factors and Treatment Options for Failure of a Two-Stage Exchange

PURPOSE OF REVIEW

Although a two-stage exchange revision is reported to have a high success rate, this strategy may fail as a treatment for prosthetic joint infection (PJI). When it does, resection arthroplasty, arthrodesis, amputation, and chronic antibiotic suppression may play a role. The purpose of this review is to determine which are the main risk factors for a two-stage exchange failure and to analyze the indications and results of resection arthroplasty, arthrodesis, amputation, and antibiotic chronic suppression for PJI.

RECENT FINDINGS

Recent literature demonstrates that the main risk factors for a two-stage exchange failure are as follows: hemodialysis, obesity, multiple previous procedures, diabetes mellitus, corticosteroid therapy, hypoalbuminemia, immunosuppression, rheumatological conditions, coagulation disorders, and infection due to multidrug-resistant (MDR) bacteria or fungal species. Regarding microorganisms, besides Staphylococcus aureus, Streptococcus spp., Enterobacteriaceae species such as Klebsiella pneumoniae and Enterobacter sp., Pseudomonas aeruginosa, or Acinetobacter baumannii, and fungus including Candida sp. are also considered risk factors for a two-stage exchange failure. Resection arthroplasty, arthrodesis, and amputation have a limited role. Chronic suppression is an option for high-risk patients or unfeasible reconstruction. In summary, we report the main risk factors for a two-stage exchange failure and alternative procedures when it occurs. Future research on patient-specific risk factors for a two-stage exchange may aid surgical decision-making and optimization of outcomes.

Culture-Negative Periprosthetic Joint Infection: An Update on What to Expect

Background:

Culture-negative periprosthetic joint infection (PJI) is a challenging condition to treat. The most appropriate management of culture-negative PJI is not known, and there is immense variability in the treatment outcome of this condition. The purpose of this study was to elucidate the characteristics, outcomes, and risk factors for failure of treatment of culture-negative PJI.

Methods:

A retrospective review of 219 patients (138 hips and 81 knees) who had undergone surgery for the treatment of culture-negative PJI was performed utilizing a prospectively collected institutional PJI database. PJIs for which the results of culture were unavailable were excluded. An electronic query and manual review of the medical records were completed to obtain patient demographics, treatment, microbiology data, comorbidities, and other surgical characteristics. Treatment failure was assessed using the Delphi consensus criteria.

Results:

The prevalence of suspected culture-negative PJI was 22.0% (219 of 996), and the prevalence of culture-negative PJI as defined by the Musculoskeletal Infection Society (MSIS) was 6.4% (44 of 688). Overall, the rate of treatment success was 69.2% (110 of 159) in patients with >1 year of follow-up. Of the 49 culture-negative PJIs for which treatment failed, 26 (53.1%) subsequently had positive cultures; of those 26, 10 (38.5%) were positive for methicillin-sensitive Staphylococcus aureus. The rate of treatment success was greater (p = 0.019) for patients who had 2-stage exchange than for those who underwent irrigation and debridement.

Conclusions:

The present study demonstrates that culture-negative PJI is a relatively frequent finding with unacceptable rates of treatment failure. Every effort should be made to isolate the infecting organism prior to surgical intervention, including extending the incubation period for cultures, withholding antibiotics prior to obtaining culture specimens, and possibly using newly introduced molecular techniques.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence

Diagnosis of Streptococcus canis periprosthetic joint infection: the utility of next-generation sequencing

A 62-year-old man who had undergone a primary knee arthroplasty 3 years earlier, presented to the emergency department with an infected prosthesis. He underwent prosthesis resection. All cultures failed to identify the infecting organism. Analysis of the intraoperative samples by next-generation sequencing revealed Streptococcus canis (an organism that resides in the oral cavity of dogs). It was later discovered that the patient had sustained a dog scratch injury several days earlier. The patient reports that his dog had licked the scratch. Treatment was delivered based on the sensitivity of S. canis, and the patient has since undergone reimplantation arthroplasty.

A positive bacterial culture during re-implantation is associated with a poor outcome in two-stage exchange arthroplasty for deep infection

Aims

The aim of this study was to identify the incidence of positive cultures during the second stage of a two-stage revision arthroplasty and to analyse the association between positive cultures and an infection-free outcome.

Patients and Methods

This single-centre retrospective review of prospectively collected data included patients with a periprosthetic joint infection (PJI) of either the hip or the knee between 2013 and 2015, who were treated using a standardised diagnostic and therapeutic algorithm with two-stage exchange. Failure of treatment was assessed according to a definition determined by a Delphi-based consensus. Logistic regression analysis was performed to assess the predictors of positive culture and risk factors for failure. The mean follow-up was 33 months (24 to 48).

Results

A total of 163 two-stage revision arthroplasties involving 84 total hip arthroplasties (THAs) and 79 total knee arthroplasties (TKAs) were reviewed. In 27 patients (16.6%), ≥ 1 positive culture was identified at re-implantation and eight (29.6%) of these subsequently failed compared with 20 (14.7%) patients who were culture-negative. The same initially infecting organism was isolated at re-implantation in nine of 27 patients (33.3%). The organism causing re-infection in none of the patients was the same as that isolated at re-implantation. The risk of the failure of treatment was significantly higher in patients with a positive culture (odds ratio (OR) 1.7; 95% confidence interval (CI) 1.0 to 3.0; p = 0.049) and in patients with a higher Charlson Comorbidity Index (OR 1.5; 95% CI 1.6 to 1.8; p = 0.001).

Conclusion

Positive culture at re-implantation was independently associated with subsequent failure. Surgeons need to be aware of this association and should consider the medical optimisation of patients with severe comorbidities both before and during treatment. Cite this article: Bone Joint J 2017;99-B:1490–5.

Decreased Hospital Costs and Surgical Site Infection Incidence With a Universal Decolonization Protocol in Primary Total Joint Arthroplasty

BACKGROUND

Staphylococcus aureus colonization has been identified as a key modifiable risk factor in the reduction of surgical site infections (SSI) related to elective total joint arthroplasty (TJA). We investigated the incidence of SSIs and cost-effectiveness of a universal decolonization protocol without screening consisting of nasal mupirocin and chlorhexidine before elective TJA compared to a program in which all subjects were screened for S aureus and selectively treated if positive.

METHODS

We reviewed 4186 primary TJAs from March 2011 through July 2015. Patients were divided into 2 cohorts based on the decolonization regimen used. Before May 2013, 1981 TJA patients were treated under a "screen and treat" program while the subsequent 2205 patients were treated under the universal protocol. We excluded the 3 months around the transition to control for treatment bias. Outcomes of interest included SSI and total hospital costs.

RESULTS

With a universal decolonization protocol, there was a significant decrease in both the overall SSI rate (5 vs 15 cases; 0.2% vs 0.8%; P = .013) and SSIs caused by S aureus organisms (2 vs 10; 0.09% vs 0.5%; P = .01). A cost analysis accounting for the cost to administer the universal regimen demonstrated an actual savings of $717,205.59. TJA complicated by SSI costs 4.6× more to treat than that of an uncomplicated primary TJA.

CONCLUSION

Our universal decolonization paradigm for elective TJA is effective in reducing the overall rate of SSIs and promoting economic gains for the health system related to the downstream savings accrued from limiting future reoperations and hospitalizations.

Management of Resistant, Atypical and Culture-negative Periprosthetic Joint Infections after Hip and Knee Arthroplasty

BACKGROUND

Periprosthetic joint infection (PJI) is a devastating complication following lower extremity total joint arthroplasty (TJA). It is a leading cause of morbidity and revision following TJA. As such, PJI is a significant driver of healthcare costs. The prevalence of PJI related to resistant and atypical organisms is increasing, and approximately 10-30% of PJIs are culture-negative. The purpose of this review is to summarize the current epidemiology, diagnostics, and management of PJI associated with resistant and atypical pathogens and of culture-negative PJIs.

METHODS

The published literature related to the epidemiology, diagnosis, and management of atypical, drug-resistant, and culture-negative PJI is reviewed.

RESULTS

The clinical diagnosis of PJI is often challenging, particularly when pathogens are fastidious or when antibiotics have been administered empirically. Molecular diagnostic studies, such as synovial α-defensin, may provide rapid, accurate identification of PJI, even in the setting of concurrent antibiotics administration or systemic inflammatory disease. Once PJI is diagnosed, two-stage exchange arthroplasty remains the gold standard for treating PJI with resistant microorganisms, since there is a high rate of treatment failure with irrigation and debridement and with one-stage exchange arthroplasty.

CONCLUSION

Additional research is needed to define the optimal treatment of PJIs associated with rare pathogens, such as fungi and mycobacteria. There is a need for inexpensive, reliable tests that rapidly detect specific microbial species and antimicrobial susceptibilities. Additional research is also required to define the specific organisms, clinical scenarios, surgical techniques, and antimicrobial regimens that allow for reproducible treatment success with prosthetic retention strategies.

Positive Culture During Reimplantation Increases the Risk of Subsequent Failure in Two-Stage Exchange Arthroplasty

BACKGROUND

It is strongly recommended that tissue and synovial fluid culture samples be obtained during reimplantation performed as part of a 2-stage exchange arthroplasty. The rate of positive cultures during reimplantation and the influence of positive cultures on subsequent outcomes, to our knowledge, are unknown. This study was designed to determine the rate of positive cultures during reimplantation and to investigate the association between positive cultures at reimplantation and subsequent outcomes.

METHODS

We retrospectively reviewed the data of 259 patients who met the Musculoskeletal Infection Society criteria for periprosthetic joint infection (PJI) and who underwent both stages of 2-stage exchange arthroplasty at our institution from 1999 to 2013. Among these patients were 267 PJIs (186 knees and 81 hips); 33 (12.4%) had ≥1 positive culture result at reimplantation. Treatment failure was assessed according to the Delphi-based consensus definition. Logistic regression analysis was performed to assess the predictors of positive culture and risk factors for failure of 2-stage exchange arthroplasty.

RESULTS

Of the 33 cases with PJI, 15 (45.5%) had a subsequent failure of the 2-stage exchange arthroplasty compared with 49 (20.9%) of the cases that were culture-negative at reimplantation. When controlling for other variables using multivariate analyses, the risk of treatment failure was higher (odds ratio = 2.53; 95% confidence interval [CI] = 1.13 to 5.64) and reinfection occurred earlier (hazard ratio = 2.00; 95% CI = 1.05 to 3.82) for the cases with a positive culture during reimplantation. The treatment failure rate did not differ (p = 0.73) between cases with ≥2 positive cultures (36.4%) and 1 positive culture (50%).

CONCLUSIONS

Positive intraoperative culture at the time of reimplantation, regardless of the number of positive samples, was independently associated with >2 times the risk of subsequent treatment failure and earlier reinfection. Surgeons should be aware that a positive culture at the time of reimplantation independently increases the risk of subsequent failure.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Resection arthroplasty for periprosthetic infection after total elbow arthroplasty

BACKGROUND

Periprosthetic infection after total elbow arthroplasty (TEA) is a serious complication that has no clearly defined treatment. The purpose of this study was to report the outcomes of resection arthroplasty for treatment of infection after TEA and the factors influencing the result.

METHODS

Ten elbows (9 patients) underwent resection arthroplasty for treatment of infection after TEA. The mean follow-up duration was 52.4 (range, 24-113) months. According to remnant distal humerus bone stock, we divided the elbows into 3 groups: lateral column, medial column, and both columns.

RESULTS

The average time to resolution of symptoms of clinical infection and normalization of serologic marker levels was 6.8 (range, 5-12) and 68.5 (range, 20-148) days after resection. The mean Mayo Elbow Performance Score and Disabilities of the Arm, Shoulder, and Hand score changed from 50.0 (range, 40-60) and 46.5 (range, 29-67) preoperatively to 73.5 (range, 55-85) and 53.0 (range, 33-65) at the last follow-up (P < .001 and P < .001, respectively). Although it was insignificant, the both-columns group showed better functional outcomes (Mayo Elbow Performance Score, 80.0; Disabilities of the Arm, Shoulder, and Hand score, 43.7) than the lateral (74.0, 54.6) or medial (62.5, 63.0) column group. The mean satisfaction score was 70.0 (range, 50-80) at the final follow-up. Only 1 case required additional operations to treat recurrent infection. There were no refractory infections, fractures, or permanent nerve lesions.

CONCLUSION

Resection arthroplasty can be an acceptable salvage treatment for infection after TEA for low-demand patients. To achieve success, both columns of the distal humerus must be preserved at implant removal.