Augmented Total Elbow Arthroplasty with Femoral Strut Allograft for Revision of Prosthetic Joint Infection with Distal Humerus Bone Loss and Incomplete Union of Periprosthetic Humeral Shaft Fracture

Abstract

Total elbow arthroplasty (TEA) prosthetic joint infection (PJI) in the setting of distal humerus bone loss poses a challenge for restoration of function. This can be complicated by a periprosthetic humeral fracture. Revision surgery in the setting of these pathologies possesses a significant challenge, especially when two or, in this case, all three problems are treated simultaneously. We present the clinical course, operative findings, and definitive treatment with the use of an augmented total elbow arthroplasty and femoral strut allograft reinforcement in detail. A review of the literature regarding the identification and management of infected TEA with augmented prosthesis and bone allograft augmentation of humerus fractures will be outlined in this case report.

Figure 1

(a–c) Preoperative X-ray imaging of the operative left elbow showing prosthetic loosening and periprosthetic fracture. (a) AP imaging of the left elbow with new periprosthetic fracture of the medial epicondyle and significant soft tissue swelling. (b) Oblique imaging of the left elbow again demonstrating a periprosthetic fracture of the medial epicondyle and lucency around the lateral aspect of the humeral implant. (c) Lateral X-ray of the left elbow demonstrating both ulnar and humeral component lucency concerning for infection.

Figure 2

(a, b) Intraoperative images showing active infection at the time of the first stage of revision surgery. (a) Posterior aspect of the left arm and elbow with abscess with a lateral paratricipital region and direct communication to a joint (white ∗) and (b) close-up of walled off abscess of the left elbow.

Figure 3

(a, b) Five-month postoperative images following first-stage revision surgery. (a) AP humeral X-rays showing delayed healing of the humeral shaft fracture and antibiotic spacer of the humerus, ulna, and elbow joint. (b) Lateral humerus X-ray showing incomplete healing of the humeral shaft fracture.

Figure 4

Intraoperative images showing a “sandwich” technique of the femoral strut allograft and total elbow arthroplasty with 50 mm distal augment. Triceps tendon (black <) released off the ulna in a continuous sleeve with anconeus muscle. Ulnar nerve (yellow ∗) marked with a vessel loop to ensure protection throughout the procedure.

Figure 5

(a–c) 9-month postoperative clinic photos showing functional motion (10-130 degrees). (a, b) Symmetric elbow flexion with 130 degrees of the surgical elbow and 140 of the contralateral elbow. (c) Symmetric elbow extension with the surgical (left) elbow demonstrating 10 degrees short of full extension compared to the full extension of the contralateral elbow.

Figure 6

(a–d) 12-month postoperative X-ray images: (a) lateral humerus X-ray; (b) AP humeral X-ray; (c) lateral elbow X-ray; (d) AP elbow X-ray.