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.
We recently reviewed the Mayo Clinic experience with resection arthroplasty for the treatment of infection after total elbow replacement.
What to Watch For
Pitfalls & Challenges