Revision total elbow arthroplasty for prosthetic fractures

Background: Fractures of total elbow arthroplasty components are uncommon, and the literature provides little guidance regarding the management and outcomes of treatment of these complications. The goal of this report was to investigate the prevalence and management of fractures of ulnar and humeral components following total elbow arthroplasty and to review our experience with cement-within-cement reconstruction for revision following such fractures. Methods: Between 1979 and 2003, twenty-four patients with a total of twenty-seven fractured total elbow arthroplasty components (seventeen ulnar and ten humeral) of different designs presented to our institution. Twenty-six implants underwent subsequent revision elbow arthroplasty at our institution. Fourteen of those revisions were done with a cement-within-cement technique, and twelve, with traditional methods. Twenty-one patients (twenty-three implants) were available for final follow-up, and data that had been acquired prospectively and entered into the institutional arthroplasty database were reviewed retrospectively. At the time of final follow-up, the Mayo Elbow Performance Score (MEPS) was calculated and preoperative, postoperative, and most recent radiographs were examined for bone loss, bushing wear, and integrity of the bone-cement interface. Results: The prevalences of humeral and ulnar component fracture following primary total elbow arthroplasties performed at our institution were 0.65% and 1.2%, respectively. At a mean of 5.1 years following revisions for those fractures, the MEPS was excellent for eight patients, good for five, fair for six, and poor for two. The average MEPS was 82 points following the revision total elbow arthroplasties done with the cement-within-cement technique and 78 points following the revisions done with the traditional method of cement removal and insertion of a revision component. Complications included seven intraoperative cortical perforations; five nerve injuries, two of which were permanent; three triceps avulsions; and one deep infection. Conclusions: Implant fractures following total elbow arthroplasty are uncommon. They occur for several reasons, such as notch sensitivity, component design, and high stresses due to bone deficiency. Revision techniques, such as cement-within-cement reimplantation, are reliable for relieving pain and restoring function; however, the rate and spectrum of complications are a cause for concern. Level of Evidence: Therapeutic Level IV.