Authors: Annette Billings MD, Stephen B. Schnall MD, John Itamura, MD
Title: Treatment of Infected Total Elbow Arthroplasties
Addresses: 2025 Zonal Ave. GNH 3900, Los Angeles, CA 90089
Purpose: To review results of treatment of infected total elbow arthroplasties.
Methods: A retrospective chart review was performed on nine consecutive patients treated for an infected TEA to determine demographics, procedure(s) performed, organism, antibiotic treatment and outcome of procedure(s).
Results: Nine patients (seven with rheumatoid arthritis and two status post trauma) had a revision total elbow arthroplasty performed for infection. Of the seven patients with rheumatoid arthritis, all were on immunosuppressants. Six of the nine patients were treated with two stage procedures: the first with implant removal, irrigation and debridemont and placement of antibiotic spacer and the second with reimplantation. One patient was treated with a single stage reimplantation (cultures at time of revision were positive after intraoperative stat gram stain was negative and pathology showed no acute inflammatory cells). The remaining two patients were treated with irrigation and debridemont with polyethelene exchange. All patients were treated with at least six weeks of antibiotics. Four patient cultures were positive for staph aureus, two for staph epidermis, two for ORSA, one for enterococcus in addition to staph aureus and one for enterobacter. Of the nine patients, one died prior to reimplantation, one has not been reimplanted yet, and one patient required a minor procedure to remove a cable. Of the remaining six patients, a repeat major revision was required for loosening or reinfection. Two of these six patients required five or more additional procedures.
Discussion: Although TEA is still the definitive procedure for severe degenerative joint disease with elbow pain, it is frought with complications, including infection, even in the best of hands. In other published studies, patients who cultured staph epidermis had the worst outcome in terms of eradicating the infection. In our present study, there was not a correlation between a specific organism and the need for further procedures due to recurrent or noneradicated infection. There was a correlation, however, between having a TEA, needing another elbow procedure not related to the infection (ie removal of loose body, synovectomy, or periprosthetic fracture) and recurrent infection or infection with a different organism. Porcine allograft, which has been shown to be an excellent culture medium for bacteria, was also used in all nine patients; its use may need to be reassessed.
Significance: Infected total elbow arthroplasties continue to be very challenging to treat. Every patient that was replanted, with the exception of one, required at least one major revision subsequent to their replanted elbow.