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Bernard F Morrey - One of the best experts on this subject based on the ideXlab platform.

  • the value of intraoperative histology in predicting infection in patients undergoing revision Elbow Arthroplasty
    Journal of Bone and Joint Surgery American Volume, 2013
    Co-Authors: Shahryar Ahmadi, Bernard F Morrey, Thomas M Lawrence, Joaquin Sanchezsotelo
    Abstract:

    Background: The perioperative diagnosis of infection in the setting of revision Elbow Arthroplasty may be difficult to establish. Intraoperative pathology with histology for identification of acute inflammatory changes has been reported to be of value in revision surgery after failed hip or knee Arthroplasty. The purpose of this study was to study the role of intraoperative histology in the diagnosis of infection in patients undergoing revision Elbow Arthroplasty. Methods: From 2000 to 2007, 296 consecutive revision Elbow procedures were performed at our institution. Both intraoperative histology and operative samples for culture were obtained at the time of 227 of these procedures, which form the basis of this study. Results: Histology was read as consistent with acute inflammation in patients undergoing thirty-three procedures (14.5%). Intraoperative cultures were positive in thirty-nine procedures (17.2%). Intraoperative histology was considered true positive (both histology and cultures positive) in twenty arthroplasties (8.8%), true negative (both histology and cultures were negative) in 175 arthroplasties (77.1%), false positive (the histology was positive but the culture was negative) in thirteen arthroplasties (5.7%), and false negative (the histology was negative but the culture was positive) in nineteen arthroplasties (8.4%). With regard to intraoperative histology, the sensitivity was 51.3%, the specificity was 93.1%, and the accuracy was 85.9%. The positive predictive value was 60.6% and the negative predictive value was 90.2%. Conclusions: In our study, intraoperative histology had a high specificity and negative predictive value, but a low sensitivity and positive predictive value for predicting infection in the setting of revision Elbow Arthroplasty. Intraoperative histology should be used in conjunction with other studies to definitively establish the diagnosis of infection in the setting of revision Elbow Arthroplasty. Level of Evidence: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

  • characterization of wear debris in total Elbow Arthroplasty
    Journal of Shoulder and Elbow Surgery, 2013
    Co-Authors: Bernard F Morrey, Judd S Day, Ryan M Baxter, Matthew L Ramsey, Patrick M Connor, Steven M Kurtz, Marla J Steinbeck
    Abstract:

    Background The purpose of this study was to evaluate wear debris in periprosthetic tissues at the time of revision total Elbow Arthroplasty. Polyethylene, metallic, and bone cement debris were characterized, and the tissue response was quantified. Materials and methods Capsular and medullary tissue samples were collected during revision surgery. Polyethylene debris was characterized by scanning electron microscopy after tissue digestion. The concentrations of metal and cement debris were quantified by inductively coupled plasma mass spectrometry. Tissue response was graded with a semiquantitative histologic method. Results Polyethylene particle size varied from the submicron range to over 100 μm. The mean diameter ranged from 0.6 μm to about 1 μm. Particles in the synovial tissues were larger and less abundant than those in tissues from the medullary canal. Cement, titanium alloy, and low levels of cobalt-chrome debris were also present, with cement predominating over metal debris. Histiocyte response was associated with small polyethylene particles (0.5-2 μm), and giant cells were associated with large polyethylene particles (>2 μm). Histiocyte scores positively correlated with the polyethylene particle number and the presence of metal. Discussion We have shown that periprosthetic tissues of total Elbow patients who have undergone revision for loosening and osteolysis contain polyethylene, cement, and metal debris. Although the polyethylene particles were of a size and shape that have been previously shown to result in activation of phagocytic cells, osteolysis after total Elbow Arthroplasty is a multimodal process. Because of the presence of multiple wear particle sources, a cause-and-effect relationship between polyethylene debris and osteolysis cannot be established with certainty.

  • allograft prosthetic composite reconstruction for massive bone loss including catastrophic failure in total Elbow Arthroplasty
    Journal of Bone and Joint Surgery American Volume, 2013
    Co-Authors: Mark E Morrey, Joaquin Sanchezsotelo, Matthew P Abdel, Bernard F Morrey
    Abstract:

    Introduction: 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. Methods: 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. Results: 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. Conclusions: 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. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  • the fate of Elbows with unexpected positive intraoperative cultures during revision Elbow Arthroplasty
    Journal of Bone and Joint Surgery American Volume, 2013
    Co-Authors: Andy T Wee, Bernard F Morrey, Joaquin Sanchezsotelo
    Abstract:

    Background: An intraoperative culture sample obtained during revision Elbow Arthroplasty that is unexpectedly positive poses a dilemma for the surgeon. The purpose of our study was to determine the prevalence of positive cultures during revision Elbow Arthroplasty when infection is not suspected preoperatively, and the long-term implications of these positive cultures. Methods: Two hundred and thirteen consecutive revision Elbow arthroplasties were performed at our institution between 2000 and 2007. Of these, sixteen patients had unexpected positive intraoperative cultures. Results: The majority of cultures grew either Staphylococcus epidermidis or Propionibacterium acnes. Twelve patients had more than two years of follow-up. One of the twelve patients was treated as for an infection because of unexplained early implant loosening and the isolation of Staphylococcus epidermidis. Ten of the twelve Elbows were treated as “contaminants” and did not receive long-term antibiotic treatment. Nine of these ten remained infection-free at the time of the final follow-up, while the remaining one developed an infection with a different organism. Conclusions: In our series, there was a 7.5% chance of encountering an unexpected positive result on intraoperative culture at the time of revision Elbow Arthroplasty. The majority of patients were successfully treated without antibiotics with a low rate of failure. A minority were considered as infections, typically presenting with unexplained early loosening and isolation of an organism on solid culture medium. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  • incidence and implications of early postoperative wound complications after total Elbow Arthroplasty
    Journal of Shoulder and Elbow Surgery, 2011
    Co-Authors: In Ho Jeon, Bernard F Morrey, Okechukwu A Anakwenze, Nho V Tran
    Abstract:

    Hypothesis Other than an awareness, there is little detailed information regarding wound problems after total Elbow Arthroplasty. The purpose of this study was to (1) determine the incidence of wound complications after Elbow Arthroplasty, (2) document the long-term implications, (3) characterize risk factors, and (4) discuss a management strategy. We hypothesize that the incidence of this complication can be reduced with careful preoperative planning. Materials and methods We reviewed 1749 total Elbow arthroplasties. The average patient age was 61.5 years (range; 30-91 years). Wound complications were diagnosed according to the criteria of the Centers for Disease Control and Prevention. Results We identified and studied 97 patients (5.5%) from the 1749 procedures. The most common problems were delayed healing and drainage in 34 and wound hematoma in 33, of which 9 (27%) progressed to secondary deep infection. Of the 97 patients, 86 (88.7%) healed with the retention of the implant, 24 (∼25%) progressed to a septic Elbow, and 11 (∼50%) required resection. Patients with rheumatoid arthritis represented 33% of the entire sample, but represented 45.8% of those with septic complications. Posttraumatic arthritis patients represented 58% of the entire sample and only 33% of those with septic problems ( P Conclusions The overall incidence of serious wound complications was slightly less than anticipated; however, the significance was considerable. Patients with rheumatoid arthritis are most vulnerable. Persistent wound drainage showed a high correlation for deep infection and subsequent implant removal. Anticipation of potential problems and appropriate prophylactic management may avoid wound complications.

Shawn W Odriscoll - One of the best experts on this subject based on the ideXlab platform.

  • long term outcome of custom triflange outrigger ulnar component in revision total Elbow Arthroplasty
    Journal of Shoulder and Elbow Surgery, 2018
    Co-Authors: Marie Caroline Merlet, Anthony M Vaichinger, Shawn W Odriscoll
    Abstract:

    Background Patients missing the distal humeral condyles are prone to premature bushing wear after total Elbow Arthroplasty. A midterm study has demonstrated that a custom triflange outrigger ulnar component was successful in preventing this. The aim of this study was to determine whether these results remained stable over time. Materials and methods The outcomes of 6 patients who underwent revision of a loose ulnar component using a custom triflange outrigger component were reviewed in this retrospective case study. The average patient age at the time of revision was 51. The average number of prior operations was 2 (range, 1-3). The mean follow-up was 15 years (range, 10-18 years). Results At final follow-up, the mean range of extension–flexion was 35° to 135°, and pronation–supination was 65° to 63°. The average Mayo Elbow Performance Score improved to 75 of 100. Four implants were still in place with no radiolucencies or osteolysis. Three patients required revision surgery for broken humeral stems. Two required conversion to another total Elbow Arthroplasty system after 18 and 14 years for humeral component loosening. Conclusions These components lasted an average of 4 times longer than the original ulnar components. In our experience, periarticular osteolysis caused by polyethylene wear creates a region of unsupported stem and a stress riser at the junction with the remaining well-supported stem and causes component stem fractures. The concept of an outrigger type of hinge might be useful for active patients requiring an Elbow prosthesis in the setting of deficient condyles.

  • custom triflange outrigger ulnar component in revision total Elbow Arthroplasty
    Journal of Shoulder and Elbow Surgery, 2011
    Co-Authors: Kai Nan An, Shawn W Odriscoll
    Abstract:

    Hypothesis This study describes the rationale for, and tests the hypothesis that, a custom outrigger triflange ulnar component for revision total Elbow Arthroplasty would decrease the contact stresses at the bushings and overcome excessive bushing wear in active patients who have bone and ligamentous deficiency. Materials and methods Five consecutive revisions for failed Coonrad-Morrey total Elbow arthroplasties were performed with the custom outrigger triflange ulnar component for patients with accelerated bushing wear, ulnar component loosening, and deficient humeral condyles. The mean age at the time of surgery was 48 years (range, 32-64 years). Follow-up averaged 81 months (range, 65-124 months). The average number of previous operations was 2.4 (range, 2-3). Results The Mayo Elbow Performance Score improved from 40 (range, 15-65) preoperatively to 91 (range, 80-100) at the latest follow-up. There were two excellent and three good results. There was no radiographic or clinical evidence of bushing wear at 6.8 years of follow-up (range, 5.5-10.3 years). One patient required further revision of the humeral component due to mechanical loosening, which had not been revised at the time of the index surgery. Discussion A custom outrigger triflange ulnar component is an effective alternative for revising loose Coonrad-Morrey ulnar components in active patients with absent humeral epicondyles and accelerated bushing wear. Conclusion It may be an alternative to revision with standard components until improved surgical designs addressing this problem become commercially available.

  • modes of wear after semiconstrained total Elbow Arthroplasty
    Journal of Bone and Joint Surgery American Volume, 2008
    Co-Authors: Steven H Goldberg, Shawn W Odriscoll, Graham J W King, Robert M Urban, Joshua J Jacobs, Mark S Cohen
    Abstract:

    Background: Osteolysis and aseptic loosening are increasingly recognized complications of total Elbow Arthroplasty. However, unlike the literature on total hip and knee Arthroplasty, studies describing the mechanisms of these processes after total Elbow Arthroplasty are sparse. Methods: Semiconstrained total Elbow Arthroplasty components were retrieved from sixteen Elbows (fourteen patients) at either revision surgery (at a mean of five years after implantation) for mechanical failure (fifteen Elbows) or postmortem examination (one Elbow). In all cases, the retrieved implant was the primary implant. The patterns of damage on these components were investigated with stereomicroscopy in correlation with clinical findings, serial radiographs, and histopathological observations. Results: All of the retrieved devices exhibited multiple modes of wear. Damage to the humeral and ulnar polyethylene bushings was nearly universal; twenty-seven of twenty-eight humeral bushings demonstrated asymmetrical thinning, while fifteen of sixteen ulnar bushings demonstrated elliptical plastic deformation. In addition, unintended metal-on-metal wear between bearing and nonbearing surfaces or between two nonbearing surfaces was commonly observed, typically in association with wear and deformation of the polyethylene bushings. Wear between the stem and the cement mantle was observed in most of the ulnar components. The histopathology of the periprosthetic tissues was similar in character to that observed in association with osteolysis and loosening of total hip and knee replacements, while analysis of the particulate debris revealed a preponderance of titanium alloy and polyethylene debris. Barium sulfate particles were also observed to a lesser extent. Conclusions: Multimodal wear in total Elbow replacements can lead to osteolysis, aseptic loosening, and prosthetic and periprosthetic fracture necessitating revision surgery. Polyethylene wear and damage, as well as unintended metal-on-metal wear, contribute to the periprosthetic particulate burden, which is likely pathogenic in these processes.

  • fracture and nonunion of the olecranon in total Elbow Arthroplasty
    Journal of Shoulder and Elbow Surgery, 2006
    Co-Authors: Guido Marra, Stephen H Gallay, Michael D Mckee, Shawn W Odriscoll
    Abstract:

    Background: While fracture and nonunion of the olecranon have been reported in patients undergoing total Elbow Arthroplasty, little information exists about the management and outcome of these cases. Methods: Twenty-four patients (twenty-five Elbows) were studied; fifteen (sixteen Elbows) with rheumatoid arthritis and nine with post-traumatic Elbow disorders. Twenty-three of the twenty-five Elbows presented with an olecranon fracture or nonunion prior to the reported Arthroplasty. During Arthroplasty the olecranon fragment was initially treated by tension band in sixteen Elbows, excision in four, suture fixation in two and three with stable fibrous union were left alone. Results: At an average follow-up of 66 months (range, 18 to 242), there were twelve excellent, nine good, three fair and one poor results. The mean pre-operative Mayo Elbow Performance Score improved from 42 (range, 20 to 62) points pre-operatively to 86 (range, 50 to 100) points post-operatively (p

  • importance of a radial head component in sorbie unlinked total Elbow Arthroplasty
    Clinical Orthopaedics and Related Research, 2002
    Co-Authors: Katsunori Inagaki, Shawn W Odriscoll, Patricia G Neale, Eiichi Uchiyama, Bernard F Morrey
    Abstract:

    The effects of a radial head component on total Elbow Arthroplasty kinematics and stability were evaluated using an anatomic design unlinked total Elbow prosthesis. An electromagnetic tracking device recorded motion and varus and valgus displacements under various conditions in 10 cadaveric Elbows. The motion patterns of the intact Elbows and the Sorbie-Questor total Elbow prostheses with a radial head component were similar, as both tended to have a valgus position in extension, varus at midflexion, and more valgus toward full flexion. Under conditions of simulated muscle loading, the maximum valgus and varus laxity of the Elbow prosthesis was, on average, 8.6 degrees +/- 4.0 degrees greater than normal. Without the radial head component, however, significant kinematic disturbances and instabilities were seen. The varus and valgus displacements were 13.3 degrees +/- 5.5 degrees greater than the intact Elbows. One total Elbow Arthroplasty without a radial head dislocated during testing. Increasing the muscle loading across the Elbow significantly enhanced dynamic stability of the total Elbow arthroplasties, especially in the extension half of Elbow motion where instability is greatest. However, this dynamic enhancement of stability was seen only in those Elbows in which the radial head component had been implanted. The radial head component is an important stabilizer, particularly in extension for this prosthesis, and possibly for other unlinked total Elbow prostheses. Although instability of unlinked prostheses depends on the prosthetic design, the use of a radial head replacement may be an important factor in preventing such instability. Perhaps even more importantly, a radial head component balances the load distribution across the articulation, which could decrease stress on the ulnohumeral articulation and therefore possibly reduce polyethylene wear, osteolysis, and loosening.

Graham J W King - One of the best experts on this subject based on the ideXlab platform.

  • results of linked convertible total Elbow Arthroplasty for the management of distal humeral fractures in the elderly
    Journal of Hand Surgery (European Volume), 2021
    Co-Authors: Jason Strelzow, Kenneth J Faber, George S Athwal, Tym Frank, Graham J W King
    Abstract:

    Purpose Total Elbow Arthroplasty (TEA) is increasingly used for the management of comminuted distal humeral fractures in elderly patients. There are limited data on the outcome of modern Elbow Arthroplasty designs in larger patient cohorts. The aim of the current study was to review the outcomes and complications using a cemented convertible TEA system in a linked configuration in patients with distal humeral fractures. Methods Patients with distal humeral fractures treated with TEA and a minimum of 2 years’ follow-up were reviewed. Demographic information, patient-reported outcome, functional and radiographic outcome assessments, and complications were reported. Results Forty patients met inclusion criteria; 35 were female. Median follow-up was 4 years (range, 2–13 years). Average age of patients at the index procedure was 79 ± 9 years. All implants were linked. Range of motion was: extension 16° ± 13°, flexion 127° ± 14°, supination 79° ± 11°, and pronation 73° ± 20°. Patient-reported outcome scores were: Patient-Rated Elbow Evaluation 37 ± 35, Quick–Disabilities of the Arm, Shoulder, and Hand 31 ± 31, and Mayo Elbow Performance Index 90 ± 18. Seven patients had heterotopic ossification. Lucent lines were noted predominantly in humeral implant zone V. No lucent lines were noted around the ulnar component in any radiographic zone. Complications occurred in 9 patients (22%) and 2 revisions were performed: one for infection and one for a late periprosthetic fracture. Conclusions Total Elbow Arthroplasty for fracture in elderly patients provides pain relief, functional range of motion, and good patient-reported outcome scores. No implant-related complications of this convertible implant system were encountered, but longer-term follow-up is needed. Type of study/level of evidence Therapeutic IV.

  • the lateral para olecranon approach for total Elbow Arthroplasty
    Journal of Hand Surgery (European Volume), 2013
    Co-Authors: Alexis Studer, George S Athwal, Joy C Macdermid, Kenneth J Faber, Graham J W King
    Abstract:

    Purpose To describe and evaluate the lateral para-olecranon approach for total Elbow Arthroplasty and to compare it with the paratricipital and triceps splitting approaches. Methods A total of 34 patients who underwent total Elbow Arthroplasty were evaluated: 25 with rheumatoid arthritis (28 Elbows) and 9 with fractures. The average duration of follow-up was 54 months (range, 12–105 mo). Of the 28 Elbows with rheumatoid arthritis, 17 underwent a triceps splitting approach, 6 a lateral para-olecranon, and 5 a paratricipital approach. Of the 9 fracture cases, 5 patients underwent a lateral para-olecranon and 4 a paratricipital approach. Extension strength, range of motion, Elbow function (Mayo Elbow Performance Index), and complications related to triceps insufficiency were compared for all 3 approaches. In addition, we compared triceps strength after lateral para-olecranon and paratricipital approaches with the contralateral healthy Elbow in the 9 fracture cases. Results Patients with rheumatoid arthritis had better extension torque when the prosthesis was implanted through the lateral para-olecranon approach (20 ± 8 N-m) compared with the triceps splitting (13 ± 4 N-m) or paratricipital approaches (12 ± 6 N-m). In the fracture group, the extension strength of the replaced Elbow was similar to the contralateral normal Elbow in both the paratricipital and lateral para-olecranon groups. Conclusions The lateral para-olecranon approach avoids triceps tendon detachment from and repair to the olecranon, thereby reducing the risk of triceps insufficiency while maintaining better extension strength relative to a triceps splitting approach. Type of study/level of evidence Therapeutic III.

  • landmarks for rotational alignment of the humeral component during Elbow Arthroplasty
    Journal of Bone and Joint Surgery American Volume, 2012
    Co-Authors: Marlis T Sabo, George S Athwal, Graham J W King
    Abstract:

    Background: The reference points for rotational orientation of the humeral component during Elbow Arthroplasty typically are on the articular surface or the humeral epicondyles. With bone loss, these landmarks may be compromised. Our purpose was to assess whether the flat posterior humeral cortex proximal to the olecranon fossa is a reliable landmark with which to orient the humeral component during Elbow Arthroplasty. Methods: Fifty cadaveric Elbows (mean age [and standard deviation] at the time of death, 73 ± 12 years) underwent computed tomography (CT) scans. The flexion-extension axis (FEA) was determined by sphere-fitting the capitellar surface and circle-fitting the narrowest portion of the trochlea. The posterior humeral cortical line (PCL) was drawn on the flat posterior humeral cortex proximal to the olecranon fossa. The transepicondylar axis (TEA) was determined by a line between the most prominent points on the epicondyles. The angles between the PCL and FEA and the TEA and FEA were calculated and were compared by using two-tailed t tests. Results: The PCL was externally rotated by a mean (and standard deviation) of 14.0° ± 4.2° (p 0.98 for the capitellar and trochlear centers, while the cumulative intraobserver and interobserver reliability was 0.8 and 0.5 for the FEA-PCL angle and 0.4 and 0.3 for the FEA-TEA angle. Conclusions: The posterior humeral cortex is a reproducible landmark that is externally rotated with respect to the flexion-extension axis of the distal part of the humerus. The surgeon must be aware of the need for an internal rotation correction factor and consider the influence of the patient’s sex on this correction when using the posterior humeral cortex as a landmark to avoid humeral component malrotation. Clinical Relevance: While the PCL is better than the TEA as a reference point, neither is able to accurately identify the FEA because of considerable normal variation. Future studies are needed to evaluate the effectiveness of computer-assisted techniques or a preoperative CT scan of the contralateral, unaffected Elbow in identifying rotational landmarks for the Elbow undergoing Arthroplasty.

  • the effect of implant malalignment on joint loading in total Elbow Arthroplasty an in vitro study
    Journal of Shoulder and Elbow Surgery, 2012
    Co-Authors: James R Brownhill, James A Johnson, J W Pollock, Louis M Ferreira, Graham J W King
    Abstract:

    Hypothesis Aseptic loosening is one of the leading causes of failure in total Elbow Arthroplasty. Incorrect implant positioning and alignment in other joints such as the knee have been found to lead to excessive loading and wear. Although similar alignment difficulties exist in the Elbow, the effect of implant malalignment on wear-inducing loads is not yet known. This in vitro study determined the effect of anterior malpositioning and varus-valgus and internal-external malrotations on humeral stem loading in total Elbow Arthroplasty. Methods and materials Computer-navigated linked Elbow Arthroplasty was conducted in 8 cadaveric Elbows. A modular, instrumented humeral component was used to measure loading during simulated Elbow motion while the position of the ulna relative to the humerus was recorded. Results Loading increased for all malaligned implant positions tested ( P Discussion This in vitro study showed that loading does increase after humeral component malalignment; however, further studies are required to determine the long-term effects on polyethylene wear and component loosening.

  • modes of wear after semiconstrained total Elbow Arthroplasty
    Journal of Bone and Joint Surgery American Volume, 2008
    Co-Authors: Steven H Goldberg, Shawn W Odriscoll, Graham J W King, Robert M Urban, Joshua J Jacobs, Mark S Cohen
    Abstract:

    Background: Osteolysis and aseptic loosening are increasingly recognized complications of total Elbow Arthroplasty. However, unlike the literature on total hip and knee Arthroplasty, studies describing the mechanisms of these processes after total Elbow Arthroplasty are sparse. Methods: Semiconstrained total Elbow Arthroplasty components were retrieved from sixteen Elbows (fourteen patients) at either revision surgery (at a mean of five years after implantation) for mechanical failure (fifteen Elbows) or postmortem examination (one Elbow). In all cases, the retrieved implant was the primary implant. The patterns of damage on these components were investigated with stereomicroscopy in correlation with clinical findings, serial radiographs, and histopathological observations. Results: All of the retrieved devices exhibited multiple modes of wear. Damage to the humeral and ulnar polyethylene bushings was nearly universal; twenty-seven of twenty-eight humeral bushings demonstrated asymmetrical thinning, while fifteen of sixteen ulnar bushings demonstrated elliptical plastic deformation. In addition, unintended metal-on-metal wear between bearing and nonbearing surfaces or between two nonbearing surfaces was commonly observed, typically in association with wear and deformation of the polyethylene bushings. Wear between the stem and the cement mantle was observed in most of the ulnar components. The histopathology of the periprosthetic tissues was similar in character to that observed in association with osteolysis and loosening of total hip and knee replacements, while analysis of the particulate debris revealed a preponderance of titanium alloy and polyethylene debris. Barium sulfate particles were also observed to a lesser extent. Conclusions: Multimodal wear in total Elbow replacements can lead to osteolysis, aseptic loosening, and prosthetic and periprosthetic fracture necessitating revision surgery. Polyethylene wear and damage, as well as unintended metal-on-metal wear, contribute to the periprosthetic particulate burden, which is likely pathogenic in these processes.

Joaquin Sanchezsotelo - One of the best experts on this subject based on the ideXlab platform.

  • primary linked semiconstrained total Elbow Arthroplasty for rheumatoid arthritis a single institution experience with 461 Elbows over three decades
    Journal of Bone and Joint Surgery American Volume, 2016
    Co-Authors: Joaquin Sanchezsotelo, Yaser M K Baghdadi
    Abstract:

    Background: Elbow Arthroplasty is the treatment of choice for end-stage rheumatoid arthritis (RA). The purpose of this study was to determine the long-term outcome of a linked semiconstrained Elbow Arthroplasty implant design in patients with RA. Methods: Between 1982 and 2006, 461 primary total Elbow arthroplasties using the Coonrad-Morrey prosthesis were performed in 387 patients with RA. Fifty-five of the arthroplasties were performed to treat concurrent traumatic or posttraumatic conditions. There were 305 women (365 Elbows, 79%) and 82 men (96 Elbows, 21%). Ten patients (10 Elbows) were lost to follow-up, 9 patients (10 Elbows) died, and 6 patients (6 Elbows) underwent revision surgery within the first 2 years. For the 435 Elbows (362 patients, 94%) with a minimum of 2 years of follow-up, the median follow-up was 10 years (range, 2 to 30 years). Results: At the most recent follow-up, 49 (11%) of the Elbows had undergone component revision or removal (deep infection, 10 Elbows; and mechanical failure, 39 Elbows). Eight additional Elbows were considered to have radiographic evidence of loosening. For surviving implants followed for a minimum of 2 years, the median Mayo Elbow Performance Score (MEPS) was 90 points. Bushing wear was identified in 71 (23%) of the surviving Elbows with a minimum of 2 years of radiographic follow-up; however, only 2% of the Elbows had been revised for isolated bushing wear. The rate of survivorship free of implant revision or removal for any reason was 92% (95% confidence interval [CI] = 88% to 94%) at 10 years, 83% (95% CI = 77% to 88%) at 15 years, and 68% (95% CI = 56% to 78%) at 20 years. The survivorship at 20 years was 88% (95% CI = 83% to 92%) with revision due to aseptic loosening as the end point and 89% (95% CI = 77% to 95%) with isolated bushing exchange as the end point. Risk factors for implant revision for any cause included male sex, a history of concomitant traumatic pathology, and implantation of an ulnar component with a polymethylmethacrylate surface finish. Conclusions: Elbow Arthroplasty using a cemented linked semiconstrained Elbow Arthroplasty provides satisfactory clinical results in the treatment of RA with a reasonable rate of survivorship free of mechanical failure at 20 years. Although bushing wear was identified on radiographs in approximately one-fourth of the patients, revision for isolated bushing wear was uncommon. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  • total Elbow Arthroplasty for distal humerus fractures
    Hand Clinics, 2015
    Co-Authors: Luke S Harmer, Joaquin Sanchezsotelo
    Abstract:

    Total Elbow Arthroplasty is a good treatment alternative for selected patients with distal humerus fractures. Its attractiveness is related to several factors, including the possibility of performing the procedure; leaving the extensor mechanism intact; faster, easier rehabilitation compared with internal fixation; and overall good outcomes reported in terms of both pain relief and function. Implant failure leading to revision surgery does happen, and patients must comply with certain limitations to extend the longevity of their implant. Development of high-performance implants may allow expanding the indications of Elbow Arthroplasty for fractures.

  • the value of intraoperative histology in predicting infection in patients undergoing revision Elbow Arthroplasty
    Journal of Bone and Joint Surgery American Volume, 2013
    Co-Authors: Shahryar Ahmadi, Bernard F Morrey, Thomas M Lawrence, Joaquin Sanchezsotelo
    Abstract:

    Background: The perioperative diagnosis of infection in the setting of revision Elbow Arthroplasty may be difficult to establish. Intraoperative pathology with histology for identification of acute inflammatory changes has been reported to be of value in revision surgery after failed hip or knee Arthroplasty. The purpose of this study was to study the role of intraoperative histology in the diagnosis of infection in patients undergoing revision Elbow Arthroplasty. Methods: From 2000 to 2007, 296 consecutive revision Elbow procedures were performed at our institution. Both intraoperative histology and operative samples for culture were obtained at the time of 227 of these procedures, which form the basis of this study. Results: Histology was read as consistent with acute inflammation in patients undergoing thirty-three procedures (14.5%). Intraoperative cultures were positive in thirty-nine procedures (17.2%). Intraoperative histology was considered true positive (both histology and cultures positive) in twenty arthroplasties (8.8%), true negative (both histology and cultures were negative) in 175 arthroplasties (77.1%), false positive (the histology was positive but the culture was negative) in thirteen arthroplasties (5.7%), and false negative (the histology was negative but the culture was positive) in nineteen arthroplasties (8.4%). With regard to intraoperative histology, the sensitivity was 51.3%, the specificity was 93.1%, and the accuracy was 85.9%. The positive predictive value was 60.6% and the negative predictive value was 90.2%. Conclusions: In our study, intraoperative histology had a high specificity and negative predictive value, but a low sensitivity and positive predictive value for predicting infection in the setting of revision Elbow Arthroplasty. Intraoperative histology should be used in conjunction with other studies to definitively establish the diagnosis of infection in the setting of revision Elbow Arthroplasty. Level of Evidence: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

  • allograft prosthetic composite reconstruction for massive bone loss including catastrophic failure in total Elbow Arthroplasty
    Journal of Bone and Joint Surgery American Volume, 2013
    Co-Authors: Mark E Morrey, Joaquin Sanchezsotelo, Matthew P Abdel, Bernard F Morrey
    Abstract:

    Introduction: 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. Methods: 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. Results: 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. Conclusions: 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. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  • the fate of Elbows with unexpected positive intraoperative cultures during revision Elbow Arthroplasty
    Journal of Bone and Joint Surgery American Volume, 2013
    Co-Authors: Andy T Wee, Bernard F Morrey, Joaquin Sanchezsotelo
    Abstract:

    Background: An intraoperative culture sample obtained during revision Elbow Arthroplasty that is unexpectedly positive poses a dilemma for the surgeon. The purpose of our study was to determine the prevalence of positive cultures during revision Elbow Arthroplasty when infection is not suspected preoperatively, and the long-term implications of these positive cultures. Methods: Two hundred and thirteen consecutive revision Elbow arthroplasties were performed at our institution between 2000 and 2007. Of these, sixteen patients had unexpected positive intraoperative cultures. Results: The majority of cultures grew either Staphylococcus epidermidis or Propionibacterium acnes. Twelve patients had more than two years of follow-up. One of the twelve patients was treated as for an infection because of unexplained early implant loosening and the isolation of Staphylococcus epidermidis. Ten of the twelve Elbows were treated as “contaminants” and did not receive long-term antibiotic treatment. Nine of these ten remained infection-free at the time of the final follow-up, while the remaining one developed an infection with a different organism. Conclusions: In our series, there was a 7.5% chance of encountering an unexpected positive result on intraoperative culture at the time of revision Elbow Arthroplasty. The majority of patients were successfully treated without antibiotics with a low rate of failure. A minority were considered as infections, typically presenting with unexplained early loosening and isolation of an organism on solid culture medium. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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  • the surgical treatment of periprosthetic Elbow fractures around the ulnar stem following semiconstrained total Elbow Arthroplasty
    Journal of Bone and Joint Surgery American Volume, 2011
    Co-Authors: Antonio M Foruria, Robert A Adams, Joaquin Sanchezsotelo, Bernard F Morrey
    Abstract:

    Background: Limited information exists related to the treatment of periprosthetic fractures of the ulna after semiconstrained Elbow Arthroplasty. Our goals were to characterize the clinical and radiographic features of periprosthetic fractures around the stem of a loose ulnar component and to determine the outcomes after surgical treatment. Methods: Between 1980 and 2008, thirty consecutive periprosthetic fractures around the ulnar stem were treated surgically at our institution. Eighteen fractures occurred after primary Arthroplasty, and twelve occurred after revision Arthroplasty. The mean time between the index Arthroplasty and the fracture was eight years. All ulnar components were loose. Ulnar bone loss was moderate in fourteen Elbows and severe in sixteen. Surgical reconstruction included revision of the ulnar component in all cases. Fracture fixation was achieved with a longer stemmed implant only in two Elbows. Strut allografts were used in twenty Elbows, with additional impaction graft augmentation in eight of them. Three additional Elbows were revised with impaction grafting alone, and five were reconstructed with an allograft ulnar prosthetic composite. Seven patients were lost to follow-up, one died, and one was managed with conversion to a resection Arthroplasty following a deep infection. The remaining twenty-one patients were followed for a mean of 4.9 ± 2.6 years. Results: At the time of the most recent follow-up, eighteen patients reported no pain or mild pain and three patients reported moderate pain. The mean arc of Elbow flexion and extension was 112°. The Mayo Elbow Performance Score was 82 points (with fifteen good or excellent results and six fair or poor results). Fracture-healing was achieved in the twenty-one followed patients. Complications included three deep infections, one superficial infection, one case of ulnar component loosening, and one case of transient dysfunction of both the median and radial nerves. Conclusions: Periprosthetic ulnar fractures around the stem of a loose ulnar component after total Elbow Arthroplasty usually combine implant loosening and severe bone loss. Revision of the ulnar component may require additional strut allografts, allograft-prosthetic composites, or impaction grafting. Satisfactory outcomes were seen after the majority of revisions; however, deep infections and component loosening continue to be serious complications. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

  • long term outcome of resection Arthroplasty for the failed total Elbow Arthroplasty
    Journal of Bone and Joint Surgery American Volume, 2010
    Co-Authors: Peter C Zarkadas, Robert A Adams, Joaquin Sanchezsotelo, Thomas W. Throckmorton, Benjamin Cass, Bernard F Morrey
    Abstract:

    Background: Elbow resection is a salvage procedure typically considered as a last resort in the case of refractory infection following total Elbow Arthroplasty. The goal of this study was to evaluate the long-term outcome of patients following resection Arthroplasty for the treatment of a failed total Elbow replacement. Methods: Between 1975 and 2005, fifty-one consecutive Elbows (fifty patients) were treated with resection for a deep infection following total Elbow Arthroplasty with either linked or unlinked implants. The average age at the time of Arthroplasty was fifty-two years, and the average age at the time of Elbow resection Arthroplasty was fifty-nine years. Twenty-nine patients (thirty Elbows) were contacted at an average of eleven years (range, 2.7 to twenty-eight years) postoperatively, and their outcomes were graded with use of the Mayo Elbow Performance Score and the Disabilities of the Arm, Shoulder and Hand (DASH) score. The remaining twenty patients (twenty-one Elbows) had either died (sixteen Elbows) or declined follow-up (five Elbows) and so were included only in the analysis of complications and early outcome. Results: Elbow resection resulted in an improvement in the Mayo Elbow Performance Score, from a preoperative value of 37 points to a final follow-up value of 60 points (a poor to fair result) for the twenty-nine patients contacted at long term (p < 0.05). Most of the increase in the Mayo Elbow Performance Score resulted from improvements in the pain component of the score. Of the thirty Elbows in patients who had been followed long term, eight had good results; eleven, fair results; and eleven, poor results. The DASH score averaged 71 points (range, 51 to 91 points). Complications were common and included infections in twenty-four Elbows (47%), intraoperative fractures in eighteen (35%), and permanent nerve injury in nine Elbows (18%). Stability after resection correlated with a better long-term Mayo Elbow Performance Score (p < 0.05). Conclusions: Resection Arthroplasty is a salvage option in patients with refractory infection after a total Elbow Arthroplasty and should be considered only when all other attempts to eradicate the infection have failed.

  • coonrad morrey total Elbow Arthroplasty for tumours of the distal humerus and Elbow
    Journal of Bone and Joint Surgery-british Volume, 2005
    Co-Authors: George S Athwal, Robert A Adams, P Y Chin, Bernard F Morrey
    Abstract:

    We reviewed 20 patients who had undergone a Coonrad-Morrey total Elbow Arthroplasty after resection of a primary or metastatic tumour from the Elbow or distal humerus between 1980 and 2002. Eighteen patients underwent reconstruction for palliative treatment with restoration of function after intralesional surgery and two after excision of a primary bone tumour. The mean follow-up was 30 months (1 to 192). Five patients (25%) were alive at the final follow-up; 14 (70%) had died of their disease and one of unrelated causes. Local control was achieved in 15 patients (75%). The mean Mayo Elbow Performance Score improved from 22 (5 to 45) to 75 points (55 to 95). Four reconstructions (20%) failed and required revision. Seven patients (35%) had early complications, the most frequent being nerve injury (25%). There were no infections or wound complications although 18 patients (90%) had radiotherapy, chemotherapy or both. The Coonrad-Morrey total Elbow Arthroplasty provides good relief from pain and a good functional outcome after resection of tumours of the Elbow. The rates of complications involving local recurrence of tumour (25%) and nerve injury (25%) are of concern.

  • total Elbow Arthroplasty after previous resection of the radial head and synovectomy
    Journal of Bone and Joint Surgery-british Volume, 2005
    Co-Authors: A Whaley, B F Morrey, Robert A Adams
    Abstract:

    We examined the effects of previous resection of the radial head and synovectomy on the outcome of subsequent total Elbow Arthroplasty in patients with rheumatoid arthritis. Fifteen Elbows with a history of resection and synovectomy were compared with a control group of patients who had Elbow Arthroplasty with an implant of the same design. The mean age in both groups was 63 years. In the study group, resection of the radial head and synovectomy had been undertaken at a mean of 8.9 years before Arthroplasty. The mean radiological follow-up for the 13 available patients in the study group was 5.89 years (0.3 to 11.0) and in the control group was 6.6 years (2.2 to 12.6). There were no revisions in either group. The mean Mayo Elbow performance score improved from 29 to 96 in the study group, with similar improvement in the control group (28 to 87). The study group had excellent results in 13 Elbows and good results in two. The control group had excellent results in seven and good results in six. Our experience indicates that previous resection of the radial head and synovectomy are not associated with an increased rate of revision following subsequent Arthroplasty of the Elbow. However, there was a higher rate of complication in the study group compared with the control group.

  • allograft prosthesis composite for revision of catastrophic failure of total Elbow Arthroplasty
    Journal of Bone and Joint Surgery American Volume, 2004
    Co-Authors: Pierre Mansat, Robert A Adams
    Abstract:

    Background: Revision of a failed total Elbow Arthroplasty is a challenging procedure, often associated with bone de- ficiency. The purpose of this investigation was to review our experience with a composite allograft-implant reconstruc- tion for patients with a failed total Elbow Arthroplasty. Methods: Thirteen patients (thirteen Elbows) in whom a total Elbow Arthroplasty had failed, primarily as a result of loosening of the humeral or ulnar component, were operated on with use of an allograft-prosthesis composite; the composite was placed on the humeral side in four of these patients and on the ulnar side in nine. The delay between the last total Elbow Arthroplasty and the allograft-prosthesis-composite procedure averaged eight years. Results: At an average of forty-two months after the revision, the Mayo Elbow Performance Score was excellent for four Elbows, good for three, fair for one, and poor for five. Nine of the thirteen patients had no or only slight pain in the Elbow. The mean arc of flexion was 97°, with an average of 28°(range, 0° to 60°) of extension to 125° (range, 100° to 140°) of flexion. There were seven complications affecting seven Elbows, and five of the seven required a re- vision procedure. Deep infection developed in four Elbows, and the allograft-prosthesis composite had to be removed from three. Two nonunions occurred at the allograft-humeral junction. Conclusions: An allograft-prosthesis composite can be a valuable option in selected patients with a failed total el- bow Arthroplasty with massive bone loss. The union and implant survival rates are high. Deep infection remains the main complication. Hence, we recommend the pursuit of other revision options, such as strut graft reconstruction, whenever possible before resorting to the use of an allograft-prosthesis composite in the surgical treatment of a failed total Elbow Arthroplasty with massive bone loss. Level of Evidence: Therapeutic study, Level IV (case series (no, or historical, control group)). See Instructions to Au- thors for a complete description of levels of evidence.