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Elbow Resection for Deep Infection After Total Elbow ArthroplastySurgical Technique
Joaquin Sanchez Sotelo, MD, PhD1; Peter Zarkadas, MD, FRCSC2; Thomas Throckmorton, MD3; Bernard F. Morrey, MD1
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
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Based on an original article: J Bone Joint Surg Am. 2010;92:2576-82.



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
JBJS Essential Surgical Techniques, 2012 Mar 14;02(01):e5 1-22. doi: 10.2106/JBJS.ST.K.00017
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Extract

Overview
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

Indications

Contraindications

Pitfalls & Challenges

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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