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Revision total elbow arthroplasty failure rates: the impact of primary arthroplasty failure etiology on subsequent revisions
J Shoulder Elbow Surg (2019) -, 1–8
www.elsevier.com/locate/ymse
Revision total elbow arthroplasty failure rates: the impact of primary arthroplasty failure etiology on subsequent revisions Dennis A. DeBernardis, DOa,*, John G. Horneff, MDb, Daniel E. Davis, MDb, Matthew L. Ramsey, MDb, Manuel C. Pontes, PhDc, Luke S. Austin, MDb a
Rowan School of Osteopathic Medicine, Stratford, NJ, USA Rothman Institute at Jefferson University, Philadelphia, PA, USA c Rowan University, Glassboro, NJ, USA b
Background: The number of primary total elbow arthroplasties (TEAs) performed is increasing annually, necessitating a rise in the number of revision procedures. No studies exist to illustrate reliable indications for revision arthroplasty. The purpose of this study was to determine the impact of the etiology of primary TEA failure on the failure rate of revision surgery. Methods: We retrospectively analyzed the patient charts of all revision TEAs performed at a single institution between 2006 and 2016. The primary outcome was revision failure, defined as the need for a second revision surgical procedure. Patients were organized into cohorts by etiology of primary implant failure. Failure rates, time to second revision, and average number of additional revisions were compared among cohorts. Results: A total of 46 patients with a mean age of 62.7 years and minimum 2-year follow-up were included. The etiologies of failure identified were infection (n ¼ 20), aseptic loosening (n ¼ 17), periprosthetic fracture (n ¼ 6), and bushing wear (n ¼ 3). All noninfectious etiologies were grouped into an additional cohort. Patients who underwent revision for infection demonstrated a significantly greater failure rate and greater number of additional revisions per patient than those with aseptic loosening, those with periprosthetic fracture, and the noninfectious group, as well as a shorter time to failure than the noninfectious group. Conclusion: Patients in whom primary TEA fails because of infection are more likely to experience revision failure and require a greater number of subsequent operations than patients with other etiologies of primary TEA failure. These data question the efficacy of revision surgery in the treatment of infected TEAs. Level of evidence: Level IV; Case Series; Treatment Study Ó 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Total elbow arthroplasty; revision; infection; loosening; failure; periprosthetic fracture
Institutional review board approval was received from the Jefferson Office of Human Research Institutional Review Board (control no. 18D.023).
*Reprint requests: Dennis A. DeBernardis, DO, Rowan School of Osteopathic Medicine, One Medical Center Drive, Stratford, NJ 08084, USA. E-mail address: [email protected] (D.A. DeBernardis).
1058-2746/$ - see front matter Ó 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. https://doi.org/10.1016/j.jse.2019.10.010
2 Total elbow arthroplasty (TEA) is an effective means to address pathology about the elbow affecting joint stability, range of motion, or the ability to function pain free.4,7,11 Although TEA is not performed as commonly as hip and knee arthroplasty, a consistent annual increase in the number of primary TEAs performed for all indications has been reported in the literature.16 A few well-studied indications for performing this procedure include posttraumatic arthritis, acute trauma resulting in fracture of the distal humerus, and inflammatory arthropathies such as rheumatoid arthritis.4,7,11 Although inflammatory arthritis has traditionally been the primary indication for performing TEA, a shift toward acute trauma in the younger individual has been demonstrated in the literature. One recent study reported an increase in TEAs being performed for acute trauma from 43% to 69% between 1997 and 2006.4,5 It is this shift in indications for the management of trauma in a younger, more high-demand population, as well as the rising number of primary TEAs performed annually, that challenges the endurance of primary arthroplasties and necessitates a natural increase in revision TEA.2,4,10,16 Although the common indications for performing primary TEA have been studied and validated, few studies have sought to recommend appropriate indications for performing revision TEA. Patients undergoing primary TEA are at risk of implant failure secondary to a number of known complications, including aseptic loosening, infection, periprosthetic fracture, bushing wear, and triceps insufficiency.4,7,11 Although each of these etiologies of primary implant failure may necessitate management via revision TEA, the success and longevity of revision TEA based on the procedural indication have not been well demonstrated in the current literature. Identification of these outcomes may act to illustrate which etiologies of primary implant failure can be considered a reliable indication for performing revision TEA. The purpose of this study was to determine the failure rate of initial revision TEA based on the etiology of primary implant failure.
Materials and methods This was a retrospective, multi-cohort study in which we reviewed the medical records of all patients who had undergone revision TEA at a single tertiary care institution between 2006 and 2016 with a minimum of 2 years’ follow-up from the date of first revision. All revision TEA procedures were performed by 1 of 4 fellowship-trained shoulder and elbow orthopedic surgeons from a single institution. Patient records were reviewed for demographic data including patient age, sex, etiology of primary TEA failure, total number of revision procedures, etiology of revision failure, and dates of initial and subsequent revisions. Patients were then grouped into cohorts based on the etiology of primary TEA failure, which we considered to be the indication for performing revision TEA. Patients who received a diagnosis of infection as their etiology of failure met at least 1 of the following criteria: (1)
D.A. DeBernardis et al. positive preoperative or intraoperative culture result, (2) evidence of a sinus tract overlying the elbow on physical examination, (3) purulent drainage from the surgical incision site, (4) presence of purulence surrounding the prosthesis during revision, and (5) newonset pain in the operative elbow with an elevated preoperative erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) level. The primary outcome measure in this study was failure of initial revision TEA, which we defined as the requirement for a second revision surgical procedure, excluding planned 2-stage revision, in any patient (Fig. 1). All 2-stage revisions performed for infected TEA implants were considered 1 revision procedure, as we did not consider resection to be an initial revision and subsequent reimplantation to be a second revision surgical procedure. We calculated the failure rates of initial revision TEA by analyzing the percentage of patients within each cohort who required a second revision surgical procedure. We also calculated the average time to second revision for each patient cohort. Failure rates were compared using a statistical comparison of independent proportions. The average time to failure was compared using independent t test statistical analysis of continuous variables. Finally, the average number of additional revision procedures required after initial revision surgery was calculated and compared among cohorts. This value was calculated by dividing the total number of additional revisions performed among all patients in a given cohort by the total number of patients in that cohort. The number of additional revisions required per patient was not normally distributed within the total patient population. For this reason, Poisson regression was used to determine the statistical significance of these values. Patients were then separated into infectious and noninfectious etiology cohorts for additional statistical comparison. Failure rates, average time to second revision, and average number of additional revisions were calculated for each of these additional cohorts and compared as previously described. All statistical analysis was completed using JMP software (version 13.2; SAS Institute, Cary, NC, USA).
Results We identified a total of 46 patients who had undergone initial revision TEA at our institution between 2006 and 2016 with a minimum of 2 years’ postoperative follow-up. The mean age of this cohort was 62.7 years (range, 30-90 years) at the date of surgery. The reported patient medical history was available in the electronic medical records of 45 patients. The most prevalent comorbidities among patients in this cohort included hypertension (52.2%), hyperlipidemia (28.3%), rheumatoid arthritis (26.1%), depression (19.6%), anxiety (17.4%), and diabetes mellitus (15.2%). Of note, 13.0% of patients reported a history of cancer, and 6.5% reported a history of smoking. In the majority of patients, the implant used for revision was the Coonrad/Morrey Total Elbow prosthesis (Zimmer, Warsaw, IN, USA). Not all surgeons used the same prosthesis, and it was noted that the study cohort was not large enough to determine a significant difference in failure rates among prosthesis types. During the 10-year study period,
Revision total elbow arthroplasty failure rates
Figure 1
3
Algorithm of determination of revision total elbow arthroplasty (TEA) failure.
250 patients had undergone primary TEA at our institution; however, not all 46 patients in our revision cohort underwent primary TEA at our institution. For this reason, the initial indication for primary TEA was only available for review in 32 of the 46 patients included in our cohort. These indications included post-traumatic arthritis (n ¼ 13), rheumatoid arthritis (n ¼ 12), trauma (n ¼ 4), nonunion after previous open reduction–internal fixation of a distal humeral fracture (n ¼ 2), and primary elbow degenerative joint disease (n ¼ 1). The etiologies of primary TEA failure leading to revision TEA included infection (43.5%), aseptic loosening (37.0%), periprosthetic fracture (13.0%), and bushing wear (6.5%) (Table I). A documented preoperative workup for infection prior to revision was available for review in the electronic records of 20 patients. This workup included serum ESR and CRP level (n ¼ 20), physical examination findings (n ¼ 20), bone scan (n ¼ 2), aspiration (n ¼ 2), and Ceretec White Blood Cell scan (n ¼ 1). Intraoperative cultures were taken in all patients who underwent revision for aseptic loosening, infection, and bushing wear to confirm the etiology of failure. The results of these cultures were available for review in only 9 patients, 3 of whom were documented to have positive results. The available positive culture results demonstrated isolation of Methicillin-sensitive Staphylococcus aureus (MSSA) (n ¼ 1), Cutibacterium (formerly Propionibacterium) acnes (n ¼ 1), and coagulase-negative Staphylococcus aureus (n ¼ 1). Intraoperative cultures were not taken in patients undergoing revision for periprosthetic fracture as all fractures occurred secondary to known trauma. Of the 17 patients who underwent revision for aseptic loosening, 6 required revision of the ulnar component alone, 7 required revision of the humeral component alone, and 4 required revision of both components. Five patients who underwent revision for aseptic loosening were deemed to have poor bone stock on removal of their implants and required strut allograft supplementation at the time of initial revision. All patients who received revision for
infection underwent thorough irrigation and debridement at the time of the initial revision procedure, as well as a 6week course of postoperative intravenous antibiotics as directed by consultation with an infectious disease specialist. No patients in the infection cohort required initiation of long-term suppressive antibiotics during the study period. Of the 20 patients who underwent revision for infection, 4 required only irrigation, debridement, and bushing exchange as they had experienced infection within 4 weeks of undergoing primary TEA. The remaining 16 patients received either a single-stage revision (n ¼ 2) or a 2-stage revision with complete removal of components and placement of an antibiotic spacer in the first stage (n ¼ 14). All patients who had undergone 2-stage revision received preoperative serum ESR and CRP measurements prior to reimplantation to confirm normal values. Of the 16 patients who had undergone a single- or 2-stage revision, 4 required strut allograft supplementation at the time of reimplantation secondary to poor bone stock. In all patients who underwent revision for bushing wear, a single-stage bushing exchange was performed at the time of initial revision. Of the 6 patients who underwent revision for periprosthetic fracture, 5 had experienced fracture around the humeral component. Of these 5 patients, 4 required revision of the humeral component alone; the remaining patient required revision of both the humeral and ulnar components as the ulnar component was noted to be loose during the initial revision procedure. The sixth patient experienced fracture around the ulnar component and required revision of the ulnar component alone. Of the patients in our study undergoing revision TEA, 54% (25 of 46) required additional revision surgery and were considered to have experienced failure. Within individual cohorts, failure was found to occur in 75.0% of revisions (15 of 20) performed for infection, 41.2% of revisions (7 of 17) for aseptic loosening, 16.7% of revisions (1 of 6) for periprosthetic fracture, and 66.7% of revisions (2 of 3) for bushing wear. Among patients who underwent revision for infection, failure occurred in 100% of those
4
D.A. DeBernardis et al. Table I Outcomes of revision TEA surgery organized by etiology of TEA failure Etiology
Failure n (%)
Average time to second revision, yr
Aseptic 7 (41.18) 3.38 loosening (n ¼ 17) Bushing wear (n ¼ 3) 2 (66.67) 4.21 Infection (n ¼ 20) 15 (75.00) 2.14 Periprosthetic 1 (16.67) 3.95 fracture (n ¼ 6) Noninfectious (n ¼ 26) 10 (38.46) 3.41
Average no. of additional revisions per patient 0.59 1.33 1.80 0.17 0.58
TEA, total elbow arthroplasty.
undergoing a single-stage revision (2 of 2) and 64.3% of those undergoing a 2-stage revision (9 of 14). Failure was also noted to occur in 50% of patients who underwent revision for infection with a single- or 2-stage procedure using strut allograft (2 of 4) and in 58.3% of patients who underwent revision without the use of allograft (7 of 12). The average time to the second revision procedure was 2.14 years in patients who underwent revision for infection, 3.38 years for aseptic loosening, 3.95 years for periprosthetic fracture, and 4.21 years for bushing wear. The average number of subsequent revision procedures required per patient after initial revision TEA was 1.80 when revision was performed for infection, 0.59 for aseptic loosening, 0.17 for periprosthetic fracture, and 1.33 for bushing wear (Table I). When all noninfectious etiologies of failure were combined into a single group (aseptic loosening, periprosthetic fracture, and bushing wear; n ¼ 26), this patient cohort demonstrated a failure rate of 38% (10 of 26), a mean time to second revision TEA of 3.41 years, and an average of 0.58 additional revisions per patient. Among the 7 patients in the aseptic loosening cohort who experienced revision TEA failure, failure occurred because of repeat aseptic loosening in 4, infection in 2, and periprosthetic fracture after a fall from standing height in 1. In both patients in the bushing wear cohort who demonstrated revision TEA failure, failure was noted to occur secondary to recurrent bushing wear. Among the 15 patients in the infection cohort who had experienced revision TEA failure, failure occurred because of recurrent infection in 10, aseptic loosening in 4, and bushing wear in 1. In the single patient in the periprosthetic fracture cohort who had experienced revision TEA failure, failure was noted to occur secondary to infection. Patients undergoing initial revision TEA for infection were noted to experience a significantly greater failure rate than patients who underwent revision for aseptic loosening (P ¼ .04), patients who underwent revision for periprosthetic fracture (P ¼ .01), and the noninfectious cohort (P ¼ .01) (Figs. 2 and 3). No significant difference in the
failure rate was noted between the remaining cohorts. Similarly, no significant difference in the failure rate of revisions performed for infection using single- vs. 2-stage revision (P ¼ .308) or bulk allograft vs. no allograft (P ¼ .7711) was noted. Patients in the infection cohort who had experienced failure of their initial revision TEA demonstrated a significantly shorter time to failure than those in the noninfectious cohort (P ¼ .05) (Fig. 4). No significant difference in time to failure was noted between the remaining cohorts when compared individually with one another. Patients who initially underwent revision for infection exhibited a significantly greater number of additional revision procedures per patient than those who underwent revision for periprosthetic fracture (P ¼ .02), those who underwent revision for aseptic loosening (P ¼ .002), and the noninfectious cohort (P < .001) (Figs. 5 and 6). No significant difference in the number of additional revision procedures was noted between the remaining cohorts.
Discussion Although primary TEA durability has improved since the onset of its use, with current literature demonstrating a 5year survival rate of 72% to 84%, complications resulting in the need for revision can still be expected.7 In our study, we identified infection, aseptic loosening, periprosthetic fracture, and bushing wear as complications of primary TEA requiring revision. Aseptic loosening has been demonstrated to be the most common cause of failure in primary TEA, with some studies quoting an incidence of 7% to 15%.7,11,12 Infection and periprosthetic fracture are potentially more destructive complications that have been found to occur with incidences of 3% to 8% and 5% to 29%, respectively.7,9,11,13 Bushing wear, although often less devastating, has been demonstrated to occur with an incidence of 12%.7,11 Admittedly, reports are varied regarding this mode of failure. Some studies have demonstrated an improvement in patient pain and function after revision TEA regardless of the indication.15 When considering this treatment option, it is vital to understand the expected outcomes and probability of success to determine which complications act as appropriate indications for revision surgery. Failure rates of revision TEA vary significantly by the indication for which the revision is performed. Our data revealed a failure rate of 17% in patients who underwent revision for periprosthetic fracture. In a study by Athwal and Morrey1 in which 26 TEAs underwent revision for periprosthetic fracture, 3 patients required additional revision surgery because of component failure or infection and 2 required additional surgery secondary to triceps avulsion. This reoperation rate of 19% (5 of 26) is similar to the failure rate found in our study. We noted a failure rate of 66% in patients who underwent revision for bushing wear, which is substantially greater than the
Revision total elbow arthroplasty failure rates
5
Figure 2 Failure rates of each etiology cohort. Columns labeled with different letters indicate a statistically significant difference between values. The unlabeled column did not demonstrate a significant difference compared with the other values. Fx, fracture; TEA, total elbow arthroplasty.
failure rate of 25% found in another study evaluating patients who underwent revision for the same reason.8 This difference is likely a result of the small number of patients included in our bushing wear cohort, which would benefit from an increase in size to accurately demonstrate the likelihood of failure that can be expected when performing revision in patients for this purpose. Finally, we noted failure to occur in 41% of patients who underwent revision because of aseptic loosening of their primary TEA. In a study performed by Rhee et al12 in which patients
underwent revision for aseptic loosening by use of impaction bone grafting, a reoperation rate of 19% was reported. It is important to note that in patients who underwent revision for aseptic loosening in our study, revision was performed with multiple techniques, including the use of strut allograft. This may account for the noted difference in failure rates; however, this technique has been shown to be useful in the treatment of failed TEA secondary to aseptic loosening with poor bone stock remaining around the prosthesis.6
Figure 3 Failure rates of infectious and noninfectious etiology cohorts. Columns labeled with different letters indicate a statistically significant difference between values. TEA, total elbow arthroplasty.
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Figure 4 Average time to failure of each etiology cohort. Columns labeled with different letters indicate a statistically significant difference between values. Unlabeled columns did not demonstrate a significant difference compared with the other values. Fx, fracture; TEA, total elbow arthroplasty.
In our study, patients who underwent revision for infection demonstrated the highest rate of failure, with 75% requiring an additional revision procedure. Patients in this cohort also required the greatest number of subsequent revisions after undergoing initial revision TEA. Both of these values were significantly greater than in all other
cohorts examined in this study except for the bushing wear group. Our results suggest that patients who undergo revision for infection, regardless of the technique used, are more likely to have failure of revision surgery and will require a greater number of additional procedures than those who undergo revision for other indications. We also
Figure 5 Average number of additional revisions required per patient in each cohort after initial revision total elbow arthroplasty (TEA). Columns labeled with different letters indicate a statistically significant difference between values. The unlabeled column did not demonstrate a significant difference compared with the other values. Fx, fracture.
Revision total elbow arthroplasty failure rates
7
Figure 6 Average number of additional revisions required per patient in infectious and noninfectious cohorts after initial revision total elbow arthroplasty (TEA). Columns labeled with different letters indicate a statistically significant difference between values.
found that the infectious etiology cohort demonstrated a significantly shorter time to failure than the noninfectious cohort, indicating that failure tends to occur more quickly in patients who undergo revision for infection than in those who undergo revision for noninfectious indications. In one study evaluating the success of 2-stage revision for the treatment of infected TEAs, 6 of 19 patients (31.6%) required additional surgical procedures, 3 of which were because of recurrent infection (16%).13 Moreover, a study evaluating the outcomes of TEA reimplantation after resection arthroplasty performed for infection found that a total of 11 of 29 patients (38%) experienced revision failures, 8 of which were because of recurrent infection (28%).3 Although these reoperation rates are much lower than the 75% failure rate found in our study, our reinfection rate of 35.7% (5 of 14) after 2-stage revision of infected TEAs is only slightly greater than that found by Cheung et al.3 It is important to note that our data demonstrated an overall 50% reinfection rate (10 of 20) in patients who underwent revision for infection using all techniques, not just 2-stage revision. Regardless, the referenced studies acknowledge the high incidence of complications and significant likelihood that patients will require additional surgery after undergoing revision for infection. Several limitations exist in this study, including its retrospective design, which provided a limitation of available data in the patient electronic medical records, as well as the small number of patients included in the periprosthetic fracture and bushing wear cohorts. The sizes of these patient cohorts likely account for the lack of significance in the comparison of their failure rates with those of the remaining groups. In addition, no standardization was set in terms of the revision technique used for each etiology of primary TEA failure, as patients underwent revision by
multiple surgeons often using different techniques. Similarly, the preoperative infection workup was surgeon specific, and no standardized protocol existed among the patients in our cohort. Patients undergoing revision TEA in this study were found to experience a substantially high failure rate of 54% and overall infection rate of 28% (13 of 46) regardless of the indication for revision. To our knowledge, this is the first study to describe an overall failure rate and infection rate of revision TEA surgery performed for all indications. We believe that it is important to publish these outcomes, no matter how unfavorable, for the benefit of contributing to our understanding of the management of TEA failure. The greatest strength of this study, however, is the number of patients included in the overall study population, as this is one of the largest evaluations of patients undergoing revision TEA existing in the current literature. Prior studies have evaluated the outcomes of revision TEA when performed using specific techniques for given indications, but to our knowledge, this is the first study to evaluate and compare the failure rates of revision TEA by etiology of primary implant failure. This is also the first study to evaluate the time to failure of revision TEA and the number of additional operations to which these patients may be subjected. Our data provide insight into the outcomes and survivorship that can be expected when performing revision TEA for a given indication. They also serve to question the use of revision in the treatment of infected TEAs. Although prior studies have demonstrated that treatment with revision can provide significant improvements in function, many have also found high complication rates using this treatment method.3,9,13,14 Several other surgical treatment options for the management of infected TEAs exist at the disposal of the operating
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surgeon, including excision arthroplasty, arthrodesis, or debridement with retention of implants.9,13 Each treatment option comes with its own major complications and limitations and should be carefully selected for each individual patient based on the goals of treatment shared by the patient and surgeon.
Conclusion The purpose of this study was to determine the effect of the etiology of primary TEA failure on the outcome of revision TEA. Our results demonstrate that infection is a devastating complication of primary TEA, as patients undergoing revision for this indication experience failure more often and more quickly than those undergoing revision for other indications. Patients who undergo revision for infection are also more likely to require a greater number of additional revision operations.
Disclaimer Matthew L. Ramsey has received grants and consultant payments from Zimmer-Biomet and Integra LifeSciences, as well as stock options in Trice Medical, which are related to the subject of this work. Luke S. Austin has received royalties from Ignite Orthopedics, as well as participated in research with Zimmer-Biomet, which are related to the subject of this work. The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Athwal GS, Morrey BF. Revision total elbow arthroplasty for prosthetic fractures. J Bone Joint Surg Am 2006;88:2017-26. https://doi. org/10.2106/JBJS.E.00878
2. Celli A, Morrey BF. Total elbow arthroplasty in patients forty years of age or less. J Bone Joint Surg Am 2009;91:1414-8. https://doi.org/10. 2106/JBJS.G.00329 3. Cheung EV, Adams RA, Morrey BF. Reimplantation of a total elbow prosthesis following resection arthroplasty for infection. J Bone Joint Surg Am 2008;90:589-94. https://doi.org/10.2106/JBJS.F.00829 4. Choo A, Ramsey ML. Total elbow arthroplasty: current options. J Am Acad Orthop Surg 2013;21:427-37. https://doi.org/10.5435/JAAOS21-07-427 5. Gay DM, Lyman S, Do H, Hotchkiss RN, Marx RG, Daluiski A. Indications and reoperation rates for total elbow arthroplasty: an analysis of trends in New York State. J Bone Joint Surg Am 2012;94:110-7. https://doi.org/10.2106/JBJS.J.01128 6. Kamineni S, Morrey BF. Proximal ulnar reconstruction with strut allograft in revision total elbow arthroplasty. J Bone Joint Surg Am 2004;86-A:1223-9. https://doi.org/10.2106/00004623-20040600000015 7. Kim JM, Mudgal CS, Konopka JF, Jupiter JB. Complications of total elbow arthroplasty. J Am Acad Orthop Surg 2011;19:328. 8. Lee BP, Adams RA, Morrey BF. Polyethylene wear after total elbow arthroplasty. J Bone Joint Surg Am 2005;87:1080-7. https://doi.org/10. 2106/JBJS.D.02163 9. Peach CA, Nicoletti S, Lawrence TM, Stanley D. Two-stage revision for the treatment of the infected total elbow arthroplasty. Bone Joint J 2013;95-B:1681-6. https://doi.org/10.1302/0301-620X.95B12.31336 10. Plaschke HC, Thillemann T, Belling-Sørensen AK, Olsen B. Revision total elbow arthroplasty with the linked Coonrad-Morrey total elbow arthroplasty: a retrospective study of twenty procedures. Int Orthop 2013;37:853-8. https://doi.org/10.1007/s00264-013-1821-9 11. Ramirez MA, Cheung EV, Murthi AM. Revision total elbow arthroplasty. J Am Acad Orthop Surg 2017;25:e166-74. https://doi.org/10. 5435/JAAOS-D-15-00479 12. Rhee YG, Cho NS, Parke CS. Impaction grafting in revision total elbow arthroplasty due to aseptic loosening and bone loss. J Bone Joint Surg Am 2013;95:e74. https://doi.org/10.2106/JBJS.K.01737 13. Rudge WBJ, Eseonu K, Brown M, Warren S, Majed A, Bayley IL, et al. The management of infected elbow arthroplasty by two-stage revision. J Shoulder Elbow Surg 2018;27:879-86. https://doi.org/10. 1016/j.jse.2017.12.033 14. Streubel PN, Simone JP, Morrey BF, Sanchez-Sotelo J, Morrey ME. Infection in total elbow arthroplasty with stable components: outcomes of a staged surgical protocol with retention of the components. Bone Joint J 2016;98-B:976-83. https://doi.org/10.1302/0301-620X. 98B7.36397 15. van der Lugt JCT, Rozing PM. Outcome of revision surgery for failed primary Souter-Strathclyde total elbow prosthesis. J Shoulder Elbow Surg 2006;15:208-14. https://doi.org/10.1016/j.jse.2005.07. 009 16. Zhou H, Orvets ND, Merlin G, Shaw J, Dines JS, Price MD, et al. Total elbow arthroplasty in the United States: evaluation of cost, patient demographics, and complication rates. Orthop Rev (Pavia) 2016; 8:6113. https://doi.org/10.4081/or.2016.6113
www.elsevier.com/locate/ymse
Revision total elbow arthroplasty failure rates: the impact of primary arthroplasty failure etiology on subsequent revisions Dennis A. DeBernardis, DOa,*, John G. Horneff, MDb, Daniel E. Davis, MDb, Matthew L. Ramsey, MDb, Manuel C. Pontes, PhDc, Luke S. Austin, MDb a
Rowan School of Osteopathic Medicine, Stratford, NJ, USA Rothman Institute at Jefferson University, Philadelphia, PA, USA c Rowan University, Glassboro, NJ, USA b
Background: The number of primary total elbow arthroplasties (TEAs) performed is increasing annually, necessitating a rise in the number of revision procedures. No studies exist to illustrate reliable indications for revision arthroplasty. The purpose of this study was to determine the impact of the etiology of primary TEA failure on the failure rate of revision surgery. Methods: We retrospectively analyzed the patient charts of all revision TEAs performed at a single institution between 2006 and 2016. The primary outcome was revision failure, defined as the need for a second revision surgical procedure. Patients were organized into cohorts by etiology of primary implant failure. Failure rates, time to second revision, and average number of additional revisions were compared among cohorts. Results: A total of 46 patients with a mean age of 62.7 years and minimum 2-year follow-up were included. The etiologies of failure identified were infection (n ¼ 20), aseptic loosening (n ¼ 17), periprosthetic fracture (n ¼ 6), and bushing wear (n ¼ 3). All noninfectious etiologies were grouped into an additional cohort. Patients who underwent revision for infection demonstrated a significantly greater failure rate and greater number of additional revisions per patient than those with aseptic loosening, those with periprosthetic fracture, and the noninfectious group, as well as a shorter time to failure than the noninfectious group. Conclusion: Patients in whom primary TEA fails because of infection are more likely to experience revision failure and require a greater number of subsequent operations than patients with other etiologies of primary TEA failure. These data question the efficacy of revision surgery in the treatment of infected TEAs. Level of evidence: Level IV; Case Series; Treatment Study Ó 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Total elbow arthroplasty; revision; infection; loosening; failure; periprosthetic fracture
Institutional review board approval was received from the Jefferson Office of Human Research Institutional Review Board (control no. 18D.023).
*Reprint requests: Dennis A. DeBernardis, DO, Rowan School of Osteopathic Medicine, One Medical Center Drive, Stratford, NJ 08084, USA. E-mail address: [email protected] (D.A. DeBernardis).
1058-2746/$ - see front matter Ó 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. https://doi.org/10.1016/j.jse.2019.10.010
2 Total elbow arthroplasty (TEA) is an effective means to address pathology about the elbow affecting joint stability, range of motion, or the ability to function pain free.4,7,11 Although TEA is not performed as commonly as hip and knee arthroplasty, a consistent annual increase in the number of primary TEAs performed for all indications has been reported in the literature.16 A few well-studied indications for performing this procedure include posttraumatic arthritis, acute trauma resulting in fracture of the distal humerus, and inflammatory arthropathies such as rheumatoid arthritis.4,7,11 Although inflammatory arthritis has traditionally been the primary indication for performing TEA, a shift toward acute trauma in the younger individual has been demonstrated in the literature. One recent study reported an increase in TEAs being performed for acute trauma from 43% to 69% between 1997 and 2006.4,5 It is this shift in indications for the management of trauma in a younger, more high-demand population, as well as the rising number of primary TEAs performed annually, that challenges the endurance of primary arthroplasties and necessitates a natural increase in revision TEA.2,4,10,16 Although the common indications for performing primary TEA have been studied and validated, few studies have sought to recommend appropriate indications for performing revision TEA. Patients undergoing primary TEA are at risk of implant failure secondary to a number of known complications, including aseptic loosening, infection, periprosthetic fracture, bushing wear, and triceps insufficiency.4,7,11 Although each of these etiologies of primary implant failure may necessitate management via revision TEA, the success and longevity of revision TEA based on the procedural indication have not been well demonstrated in the current literature. Identification of these outcomes may act to illustrate which etiologies of primary implant failure can be considered a reliable indication for performing revision TEA. The purpose of this study was to determine the failure rate of initial revision TEA based on the etiology of primary implant failure.
Materials and methods This was a retrospective, multi-cohort study in which we reviewed the medical records of all patients who had undergone revision TEA at a single tertiary care institution between 2006 and 2016 with a minimum of 2 years’ follow-up from the date of first revision. All revision TEA procedures were performed by 1 of 4 fellowship-trained shoulder and elbow orthopedic surgeons from a single institution. Patient records were reviewed for demographic data including patient age, sex, etiology of primary TEA failure, total number of revision procedures, etiology of revision failure, and dates of initial and subsequent revisions. Patients were then grouped into cohorts based on the etiology of primary TEA failure, which we considered to be the indication for performing revision TEA. Patients who received a diagnosis of infection as their etiology of failure met at least 1 of the following criteria: (1)
D.A. DeBernardis et al. positive preoperative or intraoperative culture result, (2) evidence of a sinus tract overlying the elbow on physical examination, (3) purulent drainage from the surgical incision site, (4) presence of purulence surrounding the prosthesis during revision, and (5) newonset pain in the operative elbow with an elevated preoperative erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) level. The primary outcome measure in this study was failure of initial revision TEA, which we defined as the requirement for a second revision surgical procedure, excluding planned 2-stage revision, in any patient (Fig. 1). All 2-stage revisions performed for infected TEA implants were considered 1 revision procedure, as we did not consider resection to be an initial revision and subsequent reimplantation to be a second revision surgical procedure. We calculated the failure rates of initial revision TEA by analyzing the percentage of patients within each cohort who required a second revision surgical procedure. We also calculated the average time to second revision for each patient cohort. Failure rates were compared using a statistical comparison of independent proportions. The average time to failure was compared using independent t test statistical analysis of continuous variables. Finally, the average number of additional revision procedures required after initial revision surgery was calculated and compared among cohorts. This value was calculated by dividing the total number of additional revisions performed among all patients in a given cohort by the total number of patients in that cohort. The number of additional revisions required per patient was not normally distributed within the total patient population. For this reason, Poisson regression was used to determine the statistical significance of these values. Patients were then separated into infectious and noninfectious etiology cohorts for additional statistical comparison. Failure rates, average time to second revision, and average number of additional revisions were calculated for each of these additional cohorts and compared as previously described. All statistical analysis was completed using JMP software (version 13.2; SAS Institute, Cary, NC, USA).
Results We identified a total of 46 patients who had undergone initial revision TEA at our institution between 2006 and 2016 with a minimum of 2 years’ postoperative follow-up. The mean age of this cohort was 62.7 years (range, 30-90 years) at the date of surgery. The reported patient medical history was available in the electronic medical records of 45 patients. The most prevalent comorbidities among patients in this cohort included hypertension (52.2%), hyperlipidemia (28.3%), rheumatoid arthritis (26.1%), depression (19.6%), anxiety (17.4%), and diabetes mellitus (15.2%). Of note, 13.0% of patients reported a history of cancer, and 6.5% reported a history of smoking. In the majority of patients, the implant used for revision was the Coonrad/Morrey Total Elbow prosthesis (Zimmer, Warsaw, IN, USA). Not all surgeons used the same prosthesis, and it was noted that the study cohort was not large enough to determine a significant difference in failure rates among prosthesis types. During the 10-year study period,
Revision total elbow arthroplasty failure rates
Figure 1
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Algorithm of determination of revision total elbow arthroplasty (TEA) failure.
250 patients had undergone primary TEA at our institution; however, not all 46 patients in our revision cohort underwent primary TEA at our institution. For this reason, the initial indication for primary TEA was only available for review in 32 of the 46 patients included in our cohort. These indications included post-traumatic arthritis (n ¼ 13), rheumatoid arthritis (n ¼ 12), trauma (n ¼ 4), nonunion after previous open reduction–internal fixation of a distal humeral fracture (n ¼ 2), and primary elbow degenerative joint disease (n ¼ 1). The etiologies of primary TEA failure leading to revision TEA included infection (43.5%), aseptic loosening (37.0%), periprosthetic fracture (13.0%), and bushing wear (6.5%) (Table I). A documented preoperative workup for infection prior to revision was available for review in the electronic records of 20 patients. This workup included serum ESR and CRP level (n ¼ 20), physical examination findings (n ¼ 20), bone scan (n ¼ 2), aspiration (n ¼ 2), and Ceretec White Blood Cell scan (n ¼ 1). Intraoperative cultures were taken in all patients who underwent revision for aseptic loosening, infection, and bushing wear to confirm the etiology of failure. The results of these cultures were available for review in only 9 patients, 3 of whom were documented to have positive results. The available positive culture results demonstrated isolation of Methicillin-sensitive Staphylococcus aureus (MSSA) (n ¼ 1), Cutibacterium (formerly Propionibacterium) acnes (n ¼ 1), and coagulase-negative Staphylococcus aureus (n ¼ 1). Intraoperative cultures were not taken in patients undergoing revision for periprosthetic fracture as all fractures occurred secondary to known trauma. Of the 17 patients who underwent revision for aseptic loosening, 6 required revision of the ulnar component alone, 7 required revision of the humeral component alone, and 4 required revision of both components. Five patients who underwent revision for aseptic loosening were deemed to have poor bone stock on removal of their implants and required strut allograft supplementation at the time of initial revision. All patients who received revision for
infection underwent thorough irrigation and debridement at the time of the initial revision procedure, as well as a 6week course of postoperative intravenous antibiotics as directed by consultation with an infectious disease specialist. No patients in the infection cohort required initiation of long-term suppressive antibiotics during the study period. Of the 20 patients who underwent revision for infection, 4 required only irrigation, debridement, and bushing exchange as they had experienced infection within 4 weeks of undergoing primary TEA. The remaining 16 patients received either a single-stage revision (n ¼ 2) or a 2-stage revision with complete removal of components and placement of an antibiotic spacer in the first stage (n ¼ 14). All patients who had undergone 2-stage revision received preoperative serum ESR and CRP measurements prior to reimplantation to confirm normal values. Of the 16 patients who had undergone a single- or 2-stage revision, 4 required strut allograft supplementation at the time of reimplantation secondary to poor bone stock. In all patients who underwent revision for bushing wear, a single-stage bushing exchange was performed at the time of initial revision. Of the 6 patients who underwent revision for periprosthetic fracture, 5 had experienced fracture around the humeral component. Of these 5 patients, 4 required revision of the humeral component alone; the remaining patient required revision of both the humeral and ulnar components as the ulnar component was noted to be loose during the initial revision procedure. The sixth patient experienced fracture around the ulnar component and required revision of the ulnar component alone. Of the patients in our study undergoing revision TEA, 54% (25 of 46) required additional revision surgery and were considered to have experienced failure. Within individual cohorts, failure was found to occur in 75.0% of revisions (15 of 20) performed for infection, 41.2% of revisions (7 of 17) for aseptic loosening, 16.7% of revisions (1 of 6) for periprosthetic fracture, and 66.7% of revisions (2 of 3) for bushing wear. Among patients who underwent revision for infection, failure occurred in 100% of those
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D.A. DeBernardis et al. Table I Outcomes of revision TEA surgery organized by etiology of TEA failure Etiology
Failure n (%)
Average time to second revision, yr
Aseptic 7 (41.18) 3.38 loosening (n ¼ 17) Bushing wear (n ¼ 3) 2 (66.67) 4.21 Infection (n ¼ 20) 15 (75.00) 2.14 Periprosthetic 1 (16.67) 3.95 fracture (n ¼ 6) Noninfectious (n ¼ 26) 10 (38.46) 3.41
Average no. of additional revisions per patient 0.59 1.33 1.80 0.17 0.58
TEA, total elbow arthroplasty.
undergoing a single-stage revision (2 of 2) and 64.3% of those undergoing a 2-stage revision (9 of 14). Failure was also noted to occur in 50% of patients who underwent revision for infection with a single- or 2-stage procedure using strut allograft (2 of 4) and in 58.3% of patients who underwent revision without the use of allograft (7 of 12). The average time to the second revision procedure was 2.14 years in patients who underwent revision for infection, 3.38 years for aseptic loosening, 3.95 years for periprosthetic fracture, and 4.21 years for bushing wear. The average number of subsequent revision procedures required per patient after initial revision TEA was 1.80 when revision was performed for infection, 0.59 for aseptic loosening, 0.17 for periprosthetic fracture, and 1.33 for bushing wear (Table I). When all noninfectious etiologies of failure were combined into a single group (aseptic loosening, periprosthetic fracture, and bushing wear; n ¼ 26), this patient cohort demonstrated a failure rate of 38% (10 of 26), a mean time to second revision TEA of 3.41 years, and an average of 0.58 additional revisions per patient. Among the 7 patients in the aseptic loosening cohort who experienced revision TEA failure, failure occurred because of repeat aseptic loosening in 4, infection in 2, and periprosthetic fracture after a fall from standing height in 1. In both patients in the bushing wear cohort who demonstrated revision TEA failure, failure was noted to occur secondary to recurrent bushing wear. Among the 15 patients in the infection cohort who had experienced revision TEA failure, failure occurred because of recurrent infection in 10, aseptic loosening in 4, and bushing wear in 1. In the single patient in the periprosthetic fracture cohort who had experienced revision TEA failure, failure was noted to occur secondary to infection. Patients undergoing initial revision TEA for infection were noted to experience a significantly greater failure rate than patients who underwent revision for aseptic loosening (P ¼ .04), patients who underwent revision for periprosthetic fracture (P ¼ .01), and the noninfectious cohort (P ¼ .01) (Figs. 2 and 3). No significant difference in the
failure rate was noted between the remaining cohorts. Similarly, no significant difference in the failure rate of revisions performed for infection using single- vs. 2-stage revision (P ¼ .308) or bulk allograft vs. no allograft (P ¼ .7711) was noted. Patients in the infection cohort who had experienced failure of their initial revision TEA demonstrated a significantly shorter time to failure than those in the noninfectious cohort (P ¼ .05) (Fig. 4). No significant difference in time to failure was noted between the remaining cohorts when compared individually with one another. Patients who initially underwent revision for infection exhibited a significantly greater number of additional revision procedures per patient than those who underwent revision for periprosthetic fracture (P ¼ .02), those who underwent revision for aseptic loosening (P ¼ .002), and the noninfectious cohort (P < .001) (Figs. 5 and 6). No significant difference in the number of additional revision procedures was noted between the remaining cohorts.
Discussion Although primary TEA durability has improved since the onset of its use, with current literature demonstrating a 5year survival rate of 72% to 84%, complications resulting in the need for revision can still be expected.7 In our study, we identified infection, aseptic loosening, periprosthetic fracture, and bushing wear as complications of primary TEA requiring revision. Aseptic loosening has been demonstrated to be the most common cause of failure in primary TEA, with some studies quoting an incidence of 7% to 15%.7,11,12 Infection and periprosthetic fracture are potentially more destructive complications that have been found to occur with incidences of 3% to 8% and 5% to 29%, respectively.7,9,11,13 Bushing wear, although often less devastating, has been demonstrated to occur with an incidence of 12%.7,11 Admittedly, reports are varied regarding this mode of failure. Some studies have demonstrated an improvement in patient pain and function after revision TEA regardless of the indication.15 When considering this treatment option, it is vital to understand the expected outcomes and probability of success to determine which complications act as appropriate indications for revision surgery. Failure rates of revision TEA vary significantly by the indication for which the revision is performed. Our data revealed a failure rate of 17% in patients who underwent revision for periprosthetic fracture. In a study by Athwal and Morrey1 in which 26 TEAs underwent revision for periprosthetic fracture, 3 patients required additional revision surgery because of component failure or infection and 2 required additional surgery secondary to triceps avulsion. This reoperation rate of 19% (5 of 26) is similar to the failure rate found in our study. We noted a failure rate of 66% in patients who underwent revision for bushing wear, which is substantially greater than the
Revision total elbow arthroplasty failure rates
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Figure 2 Failure rates of each etiology cohort. Columns labeled with different letters indicate a statistically significant difference between values. The unlabeled column did not demonstrate a significant difference compared with the other values. Fx, fracture; TEA, total elbow arthroplasty.
failure rate of 25% found in another study evaluating patients who underwent revision for the same reason.8 This difference is likely a result of the small number of patients included in our bushing wear cohort, which would benefit from an increase in size to accurately demonstrate the likelihood of failure that can be expected when performing revision in patients for this purpose. Finally, we noted failure to occur in 41% of patients who underwent revision because of aseptic loosening of their primary TEA. In a study performed by Rhee et al12 in which patients
underwent revision for aseptic loosening by use of impaction bone grafting, a reoperation rate of 19% was reported. It is important to note that in patients who underwent revision for aseptic loosening in our study, revision was performed with multiple techniques, including the use of strut allograft. This may account for the noted difference in failure rates; however, this technique has been shown to be useful in the treatment of failed TEA secondary to aseptic loosening with poor bone stock remaining around the prosthesis.6
Figure 3 Failure rates of infectious and noninfectious etiology cohorts. Columns labeled with different letters indicate a statistically significant difference between values. TEA, total elbow arthroplasty.
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Figure 4 Average time to failure of each etiology cohort. Columns labeled with different letters indicate a statistically significant difference between values. Unlabeled columns did not demonstrate a significant difference compared with the other values. Fx, fracture; TEA, total elbow arthroplasty.
In our study, patients who underwent revision for infection demonstrated the highest rate of failure, with 75% requiring an additional revision procedure. Patients in this cohort also required the greatest number of subsequent revisions after undergoing initial revision TEA. Both of these values were significantly greater than in all other
cohorts examined in this study except for the bushing wear group. Our results suggest that patients who undergo revision for infection, regardless of the technique used, are more likely to have failure of revision surgery and will require a greater number of additional procedures than those who undergo revision for other indications. We also
Figure 5 Average number of additional revisions required per patient in each cohort after initial revision total elbow arthroplasty (TEA). Columns labeled with different letters indicate a statistically significant difference between values. The unlabeled column did not demonstrate a significant difference compared with the other values. Fx, fracture.
Revision total elbow arthroplasty failure rates
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Figure 6 Average number of additional revisions required per patient in infectious and noninfectious cohorts after initial revision total elbow arthroplasty (TEA). Columns labeled with different letters indicate a statistically significant difference between values.
found that the infectious etiology cohort demonstrated a significantly shorter time to failure than the noninfectious cohort, indicating that failure tends to occur more quickly in patients who undergo revision for infection than in those who undergo revision for noninfectious indications. In one study evaluating the success of 2-stage revision for the treatment of infected TEAs, 6 of 19 patients (31.6%) required additional surgical procedures, 3 of which were because of recurrent infection (16%).13 Moreover, a study evaluating the outcomes of TEA reimplantation after resection arthroplasty performed for infection found that a total of 11 of 29 patients (38%) experienced revision failures, 8 of which were because of recurrent infection (28%).3 Although these reoperation rates are much lower than the 75% failure rate found in our study, our reinfection rate of 35.7% (5 of 14) after 2-stage revision of infected TEAs is only slightly greater than that found by Cheung et al.3 It is important to note that our data demonstrated an overall 50% reinfection rate (10 of 20) in patients who underwent revision for infection using all techniques, not just 2-stage revision. Regardless, the referenced studies acknowledge the high incidence of complications and significant likelihood that patients will require additional surgery after undergoing revision for infection. Several limitations exist in this study, including its retrospective design, which provided a limitation of available data in the patient electronic medical records, as well as the small number of patients included in the periprosthetic fracture and bushing wear cohorts. The sizes of these patient cohorts likely account for the lack of significance in the comparison of their failure rates with those of the remaining groups. In addition, no standardization was set in terms of the revision technique used for each etiology of primary TEA failure, as patients underwent revision by
multiple surgeons often using different techniques. Similarly, the preoperative infection workup was surgeon specific, and no standardized protocol existed among the patients in our cohort. Patients undergoing revision TEA in this study were found to experience a substantially high failure rate of 54% and overall infection rate of 28% (13 of 46) regardless of the indication for revision. To our knowledge, this is the first study to describe an overall failure rate and infection rate of revision TEA surgery performed for all indications. We believe that it is important to publish these outcomes, no matter how unfavorable, for the benefit of contributing to our understanding of the management of TEA failure. The greatest strength of this study, however, is the number of patients included in the overall study population, as this is one of the largest evaluations of patients undergoing revision TEA existing in the current literature. Prior studies have evaluated the outcomes of revision TEA when performed using specific techniques for given indications, but to our knowledge, this is the first study to evaluate and compare the failure rates of revision TEA by etiology of primary implant failure. This is also the first study to evaluate the time to failure of revision TEA and the number of additional operations to which these patients may be subjected. Our data provide insight into the outcomes and survivorship that can be expected when performing revision TEA for a given indication. They also serve to question the use of revision in the treatment of infected TEAs. Although prior studies have demonstrated that treatment with revision can provide significant improvements in function, many have also found high complication rates using this treatment method.3,9,13,14 Several other surgical treatment options for the management of infected TEAs exist at the disposal of the operating
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surgeon, including excision arthroplasty, arthrodesis, or debridement with retention of implants.9,13 Each treatment option comes with its own major complications and limitations and should be carefully selected for each individual patient based on the goals of treatment shared by the patient and surgeon.
Conclusion The purpose of this study was to determine the effect of the etiology of primary TEA failure on the outcome of revision TEA. Our results demonstrate that infection is a devastating complication of primary TEA, as patients undergoing revision for this indication experience failure more often and more quickly than those undergoing revision for other indications. Patients who undergo revision for infection are also more likely to require a greater number of additional revision operations.
Disclaimer Matthew L. Ramsey has received grants and consultant payments from Zimmer-Biomet and Integra LifeSciences, as well as stock options in Trice Medical, which are related to the subject of this work. Luke S. Austin has received royalties from Ignite Orthopedics, as well as participated in research with Zimmer-Biomet, which are related to the subject of this work. The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Athwal GS, Morrey BF. Revision total elbow arthroplasty for prosthetic fractures. J Bone Joint Surg Am 2006;88:2017-26. https://doi. org/10.2106/JBJS.E.00878
2. Celli A, Morrey BF. Total elbow arthroplasty in patients forty years of age or less. J Bone Joint Surg Am 2009;91:1414-8. https://doi.org/10. 2106/JBJS.G.00329 3. Cheung EV, Adams RA, Morrey BF. Reimplantation of a total elbow prosthesis following resection arthroplasty for infection. J Bone Joint Surg Am 2008;90:589-94. https://doi.org/10.2106/JBJS.F.00829 4. Choo A, Ramsey ML. Total elbow arthroplasty: current options. J Am Acad Orthop Surg 2013;21:427-37. https://doi.org/10.5435/JAAOS21-07-427 5. Gay DM, Lyman S, Do H, Hotchkiss RN, Marx RG, Daluiski A. Indications and reoperation rates for total elbow arthroplasty: an analysis of trends in New York State. J Bone Joint Surg Am 2012;94:110-7. https://doi.org/10.2106/JBJS.J.01128 6. Kamineni S, Morrey BF. Proximal ulnar reconstruction with strut allograft in revision total elbow arthroplasty. J Bone Joint Surg Am 2004;86-A:1223-9. https://doi.org/10.2106/00004623-20040600000015 7. Kim JM, Mudgal CS, Konopka JF, Jupiter JB. Complications of total elbow arthroplasty. J Am Acad Orthop Surg 2011;19:328. 8. Lee BP, Adams RA, Morrey BF. Polyethylene wear after total elbow arthroplasty. J Bone Joint Surg Am 2005;87:1080-7. https://doi.org/10. 2106/JBJS.D.02163 9. Peach CA, Nicoletti S, Lawrence TM, Stanley D. Two-stage revision for the treatment of the infected total elbow arthroplasty. Bone Joint J 2013;95-B:1681-6. https://doi.org/10.1302/0301-620X.95B12.31336 10. Plaschke HC, Thillemann T, Belling-Sørensen AK, Olsen B. Revision total elbow arthroplasty with the linked Coonrad-Morrey total elbow arthroplasty: a retrospective study of twenty procedures. Int Orthop 2013;37:853-8. https://doi.org/10.1007/s00264-013-1821-9 11. Ramirez MA, Cheung EV, Murthi AM. Revision total elbow arthroplasty. J Am Acad Orthop Surg 2017;25:e166-74. https://doi.org/10. 5435/JAAOS-D-15-00479 12. Rhee YG, Cho NS, Parke CS. Impaction grafting in revision total elbow arthroplasty due to aseptic loosening and bone loss. J Bone Joint Surg Am 2013;95:e74. https://doi.org/10.2106/JBJS.K.01737 13. Rudge WBJ, Eseonu K, Brown M, Warren S, Majed A, Bayley IL, et al. The management of infected elbow arthroplasty by two-stage revision. J Shoulder Elbow Surg 2018;27:879-86. https://doi.org/10. 1016/j.jse.2017.12.033 14. Streubel PN, Simone JP, Morrey BF, Sanchez-Sotelo J, Morrey ME. Infection in total elbow arthroplasty with stable components: outcomes of a staged surgical protocol with retention of the components. Bone Joint J 2016;98-B:976-83. https://doi.org/10.1302/0301-620X. 98B7.36397 15. van der Lugt JCT, Rozing PM. Outcome of revision surgery for failed primary Souter-Strathclyde total elbow prosthesis. J Shoulder Elbow Surg 2006;15:208-14. https://doi.org/10.1016/j.jse.2005.07. 009 16. Zhou H, Orvets ND, Merlin G, Shaw J, Dines JS, Price MD, et al. Total elbow arthroplasty in the United States: evaluation of cost, patient demographics, and complication rates. Orthop Rev (Pavia) 2016; 8:6113. https://doi.org/10.4081/or.2016.6113