Allograft-Prosthetic Composite Reconstruction for Massive Bone Loss Including Catastrophic Failure in Total Elbow Arthroplasty
Revision total elbow arthroplasty with an allograft-prosthetic composite is a difficult salvage procedure due to massive bone loss and a compromised soft-tissue envelope. High failure rates in prior studies of patients treated with allograft-prosthetic composites and an increased burden of revision total elbow arthroplasties necessitate optimized reconstructive techniques to improve incorporation of allograft-prosthetic composites. The goal of this report is to describe novel techniques for, and outcomes of, reconstructions done with an allograft-prosthetic composite. From 2003 through 2008, twenty-five patients underwent revision total elbow arthroplasty with an allograft-prosthetic composite in the humerus (six), ulna (eighteen), or both (one). Indications included aseptic implant loosening with a fracture or cortical breach (eleven), aseptic implant loosening without fracture (three), infection (seven), failed implants (one), bone loss after hemiarthroplasty (one), nonunion (one), and resection arthroplasty (one). Three reconstructive strategies were used: intussusception of the allograft-prosthesis-composite (Type I), strut-like coaptation (Type II), and side-to-side contact between the cortices of the allograft-prosthetic composite and the host bone (Type III). The outcomes that were examined included the Mayo Elbow Performance Score (MEPS), radiographic union, and overall revision and complication rates. The mean MEPS improved from 30 points preoperatively to 84 points at the time of follow-up. Ninety-two percent of the allograft-prosthetic composites incorporated. There were eight major and four minor complications in nine patients, leading to nine reoperations in six patients. Complications included infection (three), fracture (three), nonunion (one), malunion (one), skin necrosis (one), triceps insufficiency/weakness (two), and ulnar nerve paresthesia (one). Four of the twenty-five patients had definitive resection arthroplasty, one had osteosynthesis, and one had a successful revision, so twenty-one (84%) of the twenty-five had a functional elbow. Five of seven infected joints were salvaged with staged allograft-prosthesis-composite procedures. Larger graft-host contact areas in the three types of allograft-prosthetic composites provided good functional outcomes and a high rate of union compared with prior experience and resection arthroplasty. Allograft-prosthetic composites can be a safe, reliable option with an acceptable complication rate for revision total elbow arthroplasty. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
- [Show abstract] [Hide abstract] ABSTRACT: Periprosthetic fractures around a shoulder or an elbow arthroplasty are not common, but remain a challenging complication. Osteopaenia, advanced age, female sex, and rheumatoid arthritis are medical co-morbid factors that may contribute to humeral or ulnar fractures and associated delayed healing and poorer function. Treatment strategy includes: identification of the cause of failure, exclusion the possibility of sepsis, evaluation of the local soft-tissue status, status of the prosthesis, selection of a prosthesis adapted to the revision procedure if needed and planning of the appropriate surgical technique. Classification must be used to determine the prognosis and treatment of these fractures: the location of the fracture in relation to the stem, the security of the fixation, and the quality of the bone. For fractures around an implant, if the fracture line overlaps most of the length of the prosthesis with a loose implant, revision with a long-stem implant should be considered. When the fracture overlaps the tip of the prosthesis and extends distally, open reduction and internal fixation is recommended. When the fracture is completely distal to the prosthesis and satisfactory alignment at the fracture site can be maintained with a fracture brace, then a trial of non-surgical treatment is recommended.
- [Show abstract] [Hide abstract] ABSTRACT: Osteosarcoma is a malignant tumor that primarily affects the long bones but can also involve other bones in the body. It has a bimodal distribution with peaks in the second decade of life and late adulthood. This chapter will highlight the clinical presentation, diagnosis, and treatment of osteosarcoma.
- [Show abstract] [Hide abstract] ABSTRACT: Reconstruction of the radial head can be complicated in cases of wide resection, particularly in those cases including the proximal radial shaft. In such cases, radial head replacement may not be possible because of lack of adequate bone stock. Here, we report the use of a radial head prosthesis incorporated with a vascularized fibula for immediate anatomic restoration of the forearm and elbow. We present a case of a pathologic fracture non-union in the proximal radius in a 57-year-old female with a history of multiple myeloma. Non-operative management of the fracture was unsuccessful after chemotherapy and radiation. The proximal radius and radial head were resected and reconstructed with vascularized fibula graft in conjunction with immediate radial head prosthesis. The osteotomy site healed at 6-weeks and follow-up at 1 year showed good functional outcome. We feel that the use of this construct has definite promise and may be considered for reconstruction following resection of the proximal radius. © 2014 Wiley Periodicals, Inc. Microsurgery, 2014.