Joaquin Sanchez Sotelo1, Peter Zarkadas2, Thomas Throckmorton3, Bernard F Morrey1. 1. Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for J. Sanchez-Sotelo: sanchez-sotelo.joaquin@mayo.edu. E-mail address for B.F. Morrey: morrey.bernard@mayo.edu. 2. Lions Gate Hospital, North Vancouver, BC V7L 2L7, Canada. E-mail address: peterzarkadas@mac.com. 3. Department of Orthopaedic Surgery, Campbell Clinic-University of Tennessee, 1400 South Germantown Road, Germantown, TN 38138. E-mail address: tthrockmorton@campbellclinic.com.
Abstract
INTRODUCTION: Deep infection at the site of a total elbow arthroplasty is best managed with definitive removal of the components with resection arthroplasty in selected patients. STEP 1 SKIN INCISION AND FLAP MANAGEMENT: Use a previous skin incision when possible, keep the subcutaneous flaps as thick as possible, and avoid inadvertent iatrogenic injury to the ulnar nerve. STEP 2 IDENTIFY ULNAR AND RADIAL NERVES: The location of the ulnar nerve may be unpredictable, and the radial nerve may be at risk in two different locations. STEP 3 DEAL WITH EXTENSOR MECHANISM: Access the implants through windows on the medial and lateral aspects of the triceps; whenever possible, consider an extended olecranon osteotomy when the ulnar component and cement are well fixed. STEP 4 REMOVE HUMERAL COMPONENT AND CEMENT: Removal of all retained cement after removal of the humeral component is critical. STEP 5 REMOVE ULNAR COMPONENT AND CEMENT: The ulna is much more delicate and fragile than the humerus and is prone to iatrogenic fracture. STEP 6 OBTAIN SAMPLES FOR CULTURES AND PATHOLOGICAL ANALYSIS: Send three separate samples for culture when there was at least one preoperative positive culture, and five samples when there were no positive preoperative cultures. STEP 7 PREPARE AND INSERT SPACER: Use the nozzles of cement guns to create cylinders of cement to be inserted in the ulna and humerus. STEP 8 CLOSE: For patients with compromised soft tissues, we often consult with a plastic surgeon prior to surgery to contemplate improved coverage with rotation or free flaps at the time of the resection arthroplasty. STEP 9 POSTOPERATIVE IMMOBILIZATION AND CARE: Early motion in an articulated brace may be allowed with a "stable" resection; unstable resections with substantial bone loss are best protected longer with no motion and may require a static brace. RESULTS: We recently reviewed the Mayo Clinic experience with resection arthroplasty for the treatment of infection after total elbow replacement. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.
INTRODUCTION: Deep infection at the site of a total elbow arthroplasty is best managed with definitive removal of the components with resection arthroplasty in selected patients. STEP 1 SKIN INCISION AND FLAP MANAGEMENT: Use a previous skin incision when possible, keep the subcutaneous flaps as thick as possible, and avoid inadvertent iatrogenic injury to the ulnar nerve. STEP 2 IDENTIFY ULNAR AND RADIAL NERVES: The location of the ulnar nerve may be unpredictable, and the radial nerve may be at risk in two different locations. STEP 3 DEAL WITH EXTENSOR MECHANISM: Access the implants through windows on the medial and lateral aspects of the triceps; whenever possible, consider an extended olecranon osteotomy when the ulnar component and cement are well fixed. STEP 4 REMOVE HUMERAL COMPONENT AND CEMENT: Removal of all retained cement after removal of the humeral component is critical. STEP 5 REMOVE ULNAR COMPONENT AND CEMENT: The ulna is much more delicate and fragile than the humerus and is prone to iatrogenic fracture. STEP 6 OBTAIN SAMPLES FOR CULTURES AND PATHOLOGICAL ANALYSIS: Send three separate samples for culture when there was at least one preoperative positive culture, and five samples when there were no positive preoperative cultures. STEP 7 PREPARE AND INSERT SPACER: Use the nozzles of cement guns to create cylinders of cement to be inserted in the ulna and humerus. STEP 8 CLOSE: For patients with compromised soft tissues, we often consult with a plastic surgeon prior to surgery to contemplate improved coverage with rotation or free flaps at the time of the resection arthroplasty. STEP 9 POSTOPERATIVE IMMOBILIZATION AND CARE: Early motion in an articulated brace may be allowed with a "stable" resection; unstable resections with substantial bone loss are best protected longer with no motion and may require a static brace. RESULTS: We recently reviewed the Mayo Clinic experience with resection arthroplasty for the treatment of infection after total elbow replacement. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.
Authors: Peter C Zarkadas; Benjamin Cass; Thomas Throckmorton; Robert Adams; Joaquin Sanchez-Sotelo; Bernard F Morrey Journal: J Bone Joint Surg Am Date: 2010-11-03 Impact factor: 5.284