Efficacy of 2-stage revision using a prosthesis of antibiotic-loaded acrylic cement spacer with or without cortical strut allograft in infected total elbow arthroplasty

PURPOSE

We aimed to evaluate the efficacy of a self-manufactured prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) spacer with or without cortical strut allograft in infected total elbow arthroplasty.

METHODS

Between March 2009 and February 2018, we enrolled 18 patients (mean age, 66.9 years) who underwent 2-stage revision arthroplasty for prosthetic infection following total elbow arthroplasty. After implant removal in the first stage, we performed débridement and PROSTALAC insertion. During the second stage, we performed reimplantation using a cortical strut allograft for patients with a considerably severe bone defect. The mean follow-up period was 34 months (range, 25-60 months), during which we evaluated the Mayo Elbow Performance Score (MEPS), range of motion (ROM), and blood markers.

RESULTS

In all 18 patients, infection control was ensured using intravenous (IV) antibiotic therapy for 6 weeks or IV antibiotics for 4 weeks converting to oral antibiotics for 2 weeks following PROSTALAC insertion. The mean visual analog scale score improved from 8 points preoperatively to 2 points postoperatively, and the mean MEPS improved from 32 points preoperatively to 82 points postoperatively (P < .05). The average ROMs at the last follow-up were 9° to 132° from extension to flexion, respectively. Two patients experienced ulnar nerve neuropraxia after surgery, from which they were resolved. Moreover, 2 and 4 patients developed superficial wound infection and triceps insufficiency, respectively, and there was no infection recurrence.

CONCLUSION

In the management of elbow prosthetic infection, 2-stage revision arthroplasty using PROSTALAC spacer insertion in the first stage and cortical strut allograft in the second stage for patients with severe bone defect revealed good clinical results and relatively low infection recurrence rates. However, the complication rate is substantial.

Relationship between the tilt angle of bipolar radial head prostheses and radiological radiocapitellar instability

OBJECTIVE

This study aimed to radiologically assess the relationship between the tilt angle of the bipolar radial head prostheses and radiocapitellar instability.

METHODS

In this radiological study, 28 consecutive patients (13 females and 15 males: mean age=47 years and age range=23-77 years) who underwent cemented bipolar radial head arthroplasty (Judet CRF II) because of comminuted radial head fracture with elbow instability were retrospectively reviewed.

RESULTS

There was excellent intra- and interobserver reliability for the measurements of the tilt angle and the radiocapitellar distance. ICC for interobserver reliability of the tilt angle was 0.93, and ICC for intraobserver reliability for the 2 observers was 0.96 and 0.97, respectively. ICC for interobserver reliability of the radiocapitellar distance was 0.87, and ICC for intraobserver reliability for the 2 observers was 0.91 and 0.93, respectively. The mean tilt angle was 17.6° (range=1°-35°), and the mean radiocapitellar distance was 8 mm (range=1-17 mm). Pearson's correlation revealed a strong significant positive correlation between the tilt angle and the radiocapitellar distance (r=0.77 and p<0.001).

CONCLUSION

Evidence from this study has demonstrated a strong positive correlation between the tilt angle of bipolar radial head prostheses and radiocapitellar instability. The tilt angle can be used as an indicator of radiocapitellar joint instability following bipolar radial head prostheses.

LEVEL OF EVIDENCE

Level IV, Diagnostic study.

Capitellar erosion after radial head arthroplasty: A comparative biomechanical study of operated radial head fractures on cadaveric specimens

BACKGROUND

We asked whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA), common techniques used for the confrontation of displaced or comminuted radial head fractures, are correlated with cartilage wear of the capitulum.

HYPOTHESIS

We hypothesized that neither ORIF nor RHA are correlated with capitellar cartilage wear.

MATERIAL AND METHODS

On 5 cadaveric elbow specimens, osteotomies were employed to simulate radial head comminuted fractures followed with ORIF by Herbert screws. Radial heads were also excised from other 5 cadaveric elbow specimens and were replaced by metallic monopolar implants. Finally, 2 elbows were not operated and used as a control group. Custom-made rotary machines, working unstoppably, generated 700,000 pronation and supination forearm movements at a 110° arc of motion. The elbow joints were examined with pre- and postoperative magnetic resonance imaging (MRI) scans and the articular surfaces of the capitula were resected and sent for histopathology study.

RESULTS

In the 2 cadaveric elbows of the control group and the 4 elbows treated with ORIF, no cartilage damage was found. The fifth one displayed cartilage fissures, which were, classified according to International Cartilage Repair Society (ICRS) grading system as grade I cartilage damage. On the contrary, all 5 elbows treated with RHA sustained complete cartilage loss, exposure of the subchondral bone and were classified as ICRS grade IV cartilage damage.

DISCUSSION

Our study suggests that metallic monopolar RHA after a displaced or comminuted radial head fracture carries a high risk of rapidly evolving cartilage loss of the capitulum.

Clinical and Radiographic Outcomes of Unipolar and Bipolar Radial Head Prosthesis in Patients with Radial Head Fracture: A Systemic Review and Meta-Analysis

PURPOSE

To compare clinical outcomes of unipolar and bipolar radial head prosthesis in the treatment of patients with radial head fracture.

MATERIALS AND METHODS

Medline, Cochrane, EMBASE, Google Scholar databases were searched until April 18, 2016 using the following search terms: radial head fracture, elbow fracture, radial head arthroplasty, implants, prosthesis, unipolar, bipolar, cemented, and press-fit. Randomized controlled trials, retrospective, and cohort studies were included.

RESULTS

The Mayo elbow performance score (MEPS), disabilities of the arm, shoulder, and hand (DASH) score, radiologic assessment, ROM, and grip strength following elbow replacement were similar between prosthetic devices. The pooled mean excellent/good ranking of MEPS was 0.78 for unipolar and 0.73 for bipolar radial head arthroplasty, and the pooled mean MEPS was 86.9 and 79.9, respectively. DASH scores for unipolar and bipolar prosthesis were 19.0 and 16.3, respectively. Range of motion outcomes were similar between groups, with both groups have comparable risk of flexion arc, flexion, extension deficit, rotation arc, pronation, and supination (p values <0.001 for both unipolar and bipolar prosthesis). However, bipolar radial head prosthesis was associated with an increased chance of heterotopic ossification and lucency (p values ≤0.049) while unipolar prosthesis was not (p values ≥0.088). Both groups had risk for development of capitellar osteopenia or erosion/wear (p values ≤0.039).

CONCLUSION

Unipolar and bipolar radial head prostheses were similar with respect to clinical outcomes. Additional comparative studies are necessary to further compare different radial head prostheses used to treat radial head fracture.

The Rate of Radial Head Prosthesis Removal or Revision: A Systematic Review and Meta-Analysis

PURPOSE

We conducted a meta-analysis and systematic review with the primary objective to determine the overall incidence of radial head prosthesis removal or revision. Our secondary objectives addressed the incidence of removal or revision based on the type of prosthesis fixation (cemented, uncemented smooth stem, uncemented press-fit), material (metal, Vitallium, titanium, pyrocarbon), and design (short vs long stem and monopolar vs bipolar), and the reasons for prosthetic removal or revision.

METHODS

We included 30 studies with a total of 1,017 patients out of whom 77 prostheses were removed and 45 prostheses were revised.

RESULTS

The pooled rate of radial head prosthesis removal or revision was 10.0% (95% confidence interval, 7.3%-13.6%) with a mean follow-up of 38 months. Subgroup analysis showed that the incidence of removal/revision was lowest with the cemented fixation, longer-stem, Vitallium material, and bipolar prosthesis. More than half of the prostheses were removed/revised for excision of the heterotopic ossification (47%) and for the treatment of stiffness and limitation of motion (42%). Other reasons recorded were pain (19%), loosening (16%), overstuffing (13%), instability (12%), infection (8%), and prosthesis disassembly (4%).

CONCLUSIONS

The current data show that the highest incidence of removal/revision occurred within 2 years after implantation. There was no major difference in the incidence of removal/revision among different designs and materials. Implant removal was often performed as part of a procedure to manage elbow stiffness and heterotopic ossification at the surgeon's preference, not necessarily because the implant was malfunctioning. It appears that most radial head arthroplasties have an acceptable and comparable mid-term longevity; however, it is unclear whether long-term longevity will differ between devices.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Total elbow arthroplasty under unfavourable soft tissue conditions

PURPOSE

To evaluate the clinical and radiographic outcomes of patients with total elbow arthroplasty (TEA) and soft tissue reconstruction.

METHODS

We investigated six patients who underwent TEA and soft tissue reconstruction (two elbows with 1-stage surgery and four elbows with 2-stage surgery). The mean patient age at the time of the surgical procedure was 43.2 years; the mean follow-up duration was 88.2 months.

RESULTS

The mean pain visual analogue scale (VAS) during motion was improved from 6.3 pre-operatively to 0.7 at the last follow-up. The mean Mayo Elbow Performance Score (MEPS) improved from 26.7 pre-operatively to 81.7 at the last follow-up. The mean flexion-extension arcs of the 1- and 2-stage surgery groups increased from 12.5° and 13.8° pre-operatively to 72.5° and 100° at the last follow-up, respectively. The mean MEPS of the one and two stage surgery groups were 75 and 85, respectively, at the last follow-up. One of the six elbows had loosening on the simple radiograph at the last follow-up, and there were no cases with bushing wear. Three elbows needed additional skin debridement owing to wound complications (2/2 elbows in the 1-stage surgery group and 1/4 elbows in the 2-stage surgery group).

CONCLUSIONS

Under unfavorable soft tissue conditions, performing soft tissue reconstruction with TEA provides satisfactory functional improvement and pain relief. The two stage surgery provided a lower rate of wound complication and better elbow function than the one stage surgery, which led to high patient satisfaction post-operatively.

LEVEL OF EVIDENCE

Therapeutic Level IV.

An Articulating Antibiotic Cement Spacer for First-stage Reconstruction for Infected Total Elbow Arthroplasty

Management of an infected total elbow replacement is a significant clinical challenge. Although preservation of the prosthesis is ideal, a 2-stage revision is often necessary. Unlike lower limb arthroplasty, antibiotic spacers are not commercially available. Monoblock cement spacers do not allow elbow movements and are therefore associated with severe stiffness and scarring, leading to poor clinical outcomes. In our paper we present a simple and novel technique for constructing an articulating antibiotic-impregnated spacer for use as an implant for a 1-stage revision of an infected elbow arthroplasty.

Rare implant-specific complications of the MoPyC radial head prosthesis

BACKGROUND

According to currently available data, the clinical short-term results of the MoPyC radial head prosthesis (Bioprofile, Tornier, Montbonnot-Saint-Martin, France) seem favorable. However, we have encountered several implant-specific complications in recent years. Hence, this case series reports rare complications after radial head arthroplasty with the MoPyC prosthesis to make surgeons aware of their existence and to provide information about the underlying cause and possible salvage strategies.

METHODS

A retrospective chart review from 2011 to 2016 was conducted to identify all adult patients with a minimum 2-year follow-up who underwent or were referred after radial head arthroplasty with the MoPyC radial head prosthesis and experienced implant-related complications.

RESULTS

Five patients with 7 implant-related complications were found. One patient experienced breakage of the pyrocarbon head. In another patient, breakage of the stem and-after revision surgery-partial breakage were observed. Disassembly of the prosthesis was seen in 1 case. Extensive periprosthetic stress shielding was seen in 3 patients resulting in symptomatic loosening (1), periprosthetic radial neck fracture (1), and stem migration (1).

CONCLUSIONS

Whereas clinical short-term results of the MoPyC radial head prosthesis are satisfactory, rare implant-related complications can occur. Surgeons should be aware of these complications as they may lead to a poor outcome.

Outcomes and radiographic findings of anatomic press-fit radial head arthroplasty

BACKGROUND

Radial head arthroplasty (RHA) is a popular method of treatment for complex fractures of the radial head. The purpose of this study was to investigate patient outcomes and radiographic findings associated with a single anatomic monopolar press-fit radial head system commonly used for the treatment of radial head fractures.

METHODS

A retrospective review of prospectively collected data was performed for a consecutive series of patients treated with a press-fit anatomically designed RHA between November 2007 and April 2014. The most recent radiographs were evaluated for loosening, stress shielding, and instability. Postoperative motion and outcomes were reported at most recent follow-up.

RESULTS

At an average follow-up of 30 months, 6 of the 15 patients (40%) demonstrated radiographic loosening. Six of the 9 patients (67%) without loosening demonstrated stress shielding (average, 6 mm). Functional outcome scores included a mean American Shoulder and Elbow Surgeons score of 70, Mayo Elbow Performance Score of 85, visual analog scale score for pain of 2, visual analog scale score for function of 7, and Single Assessment Numeric Evaluation score of 75. Average flexion-extension arc was 14° to 138°, and average pronation-supination was 75° to 74°. All 6 of the patients with radiographic loosening had undergone RHA with an associated ligamentous injury repair. Satisfaction among patients was high as no patient reported an unsatisfactory outcome.

CONCLUSIONS

The use of an anatomic, press-fit monopolar RHA in the management of acute complex radial head fractures has yielded excellent clinical outcomes despite high rates of radiographic loosening and stress shielding. Press-fit RHA in the setting of ligamentous injury warrants further investigation because of a high rate of implant loosening observed.

Teriparatide: an unexpected adjunct for the treatment of a long-standing infected elbow prosthesis prevented arm amputation

A 76-year-old woman with rheumatoid arthritis, osteoporosis and multiple comorbidities presented with septic left elbow prosthesis. Treatment included combination antibiotic therapy and removal of the prosthesis. Weeks later she was started on teriparatide. Her elbow symptoms resolved. In our experience, this is the first case in the literature reporting teriparatide efficacy in the treatment of septic arthritis.

Complications of radial head prostheses

Radial head prostheses are indicated for treatment of complex radial head fractures not amenable for fixation. After the initial experience with silastic implants, metallic or pyrocarbon arthroplasty have been used for 20 years. Little is known about complications related to these implants. Main complications are related to loosening whether they are cemented or not cemented. Hypotheses have been proposed like inadequate stem design, insufficient cement technique, stress shielding, and foreign body reactions secondary to polyethylene wear. Pain and stiffness are other common complications often related to oversized radial head component or overstuffing of the joint with excessive lengthening of the radius. Instability can be another complication in the context of more complex trauma with lateral collateral ligament complex lesion and coronoid fracture. Fixation of the coronoid fracture, reinsertion of the lateral collateral ligament complex, and the use of monobloc radial head prosthesis are recommended to stabilize the joint. Finally, osteoarthritis is common with follow-up.