Revision of Failed Total Elbow Arthroplasty With Osseous Deficiency: Humeral Replacement and Allograft Prosthetic Composite Reconstruction

Introduction

This chapter deals with two final options to preserve some effective function of the extremity. Other revision replacement options are discussed in Chapter 106, Chapter 107, Chapter 108 . We continue to use reinsertion into the cement host; strut grafting for deficiency and fracture and impaction grafting. However, when none of these strategies is viable ( Fig. 109.1 ), there are two remaining options to restore function: total humeral replacement and allograft prosthetic replacement (APC). Bulk allograft replacements are still used to reconstruct deficiencies after tumor resection. Total allograft replacement has been abandoned due to the eventual development of neurotrophic resorption and dysfunction.

Rationale and Perspective

In the early years of joint replacement salvage options, usually for infection, were resection or fusion. Allograft composite revision was considered unreliable. Extensive bone loss made fusion difficult at best, and the resection was dysfunctionally unstable (see Chapter 5 ). Adopting techniques from hip revision and tumor surgery we attempted allograft prosthetic reconstruction for massive bone loss in the 1990s. However, a review of 13 procedures revealed a complication rate of 55% and a success rate of only 60%, and we therefore placed a moratorium on this strategy. Still the relentless stream of what appeared as near hopeless salvage pathologies, along with the recognition of the effectiveness of strut graft augmentation, prompted reconsideration of the proposition. We abandoned the step-cut transverse-type interface and the need for plate and screw stabilization in favor of linear strut contact and monofilament wire cerclage stabilization.

Additional Considerations

The Implant

As with any revision option, having a spectrum of off-the-shelf implant options is critical and obviates the need for expensive and ineffective custom devices ( Fig. 109.2 ). We feel a linked implant is essential for a reliable outcome.

Essential Technical Concepts

The technical difficulty and the clinical inadequacy of achieving precise step-cuts prompted the concept of a side-to-side graft/host bone construct. There are three essential concepts to be realized ( Fig. 109.3 ):

• 1

  The component is fixed in a circumferentially intact graft.

• 2

  Incorporation is enhanced by extensive contact at the graft/host interface.

• 3

  Stabilization is by cerclage wire, making it independent of compromised host bone holding a screw.

• 4

  The APC is used when strut augmentation is considered inadequate.

Mayo Classification of APC Elbow Reconstruction

The classification is based on experience with three distinct types of osseous deficiencies ( Fig. 109.4 ).