Infection is one of the most devastating complications of elbow arthroplasty. Early studies reported rates as high as 11%. The incidence of infection has been more recently reported as approximately between 2 and 5%.16, 17, 18 Nevertheless, infection rates after TEA remain greater than those for total hip or knee arthroplasties. The reason for this is blieved to be due to the relative paucity of soft tissue coverage in the elbow compared to the other joints. Typical infecting organisms are Staphylococcus aureus and Staphylococcus epidemidis.19
Risk factors for infection include oral steroid use, diabetes mellitus, distant osteomyelitis, infected prostheses at other sites and history of septic arthritis in the affected elbow.
Clinical signs and symptoms may consist of:
- Decreasing range of motion
- Night sweats
- Draining sinus tract
Radiographic features of infection include:
- Progressive and extensive widening of interfaces between bone-cement, bone-prosthesis or cement-prosthesis
- Periosteal bone formation
- Periprosthetic bone resorption
- Soft tissue or periprosthetic gas
Infected total elbow arthroplasty resulting in marked widening of bone-cement interfaces, endosteal thinning of cortical bone (red arrow), and periosteal bone formation.
Infected total elbow arthroplasty. There is a large joint effusion (red arrow), distended olecranon bursa (O), and irregular interface widening about the ulnar stem (green arrow).
Chronically infected total elbow arthorplasty with wound dehiscence. Note gas (arrows) in the joint related to sinus track formation.
If there is a high clinical suspicion for infection and any of the above radiographic findings are present, the patient should be treated as though there is an infection; no further radiographic studies are necessary. Infection of elbow replacements requires aggressive treatment. The vast majority require operative management. Orthopedic management may consist of:
- Irrigation and debridement
- Considered when infection is acute
- May require repeat procedures, placing patient at risk for soft-tissue damage
- Resection arthroplasty
- Hardware removed and antibiotic impregnated cement space placed
- Eventually followed by revision arthroplasty
Cement spacers are temporary prostheses made of antibiotic impregnated methylmethacralate. The cement is prepared in the surgical site, mixed with antibiotics, and formed by the surgeon into a patty, cylinder or forms resembling the components of the elbow arthroplasty. The spacer allows for local dispersal of antibiotics to the infected joint area. Cement spacers have certain advantages because they:
- Provide local dispersal of antibiotics to the infected joint area
- Maintain length
- Minimize dead space
- Preserve soft-tissue planes
- Facilitate ease of revision arthroplasty
Articulating cement spacer. The ulnar component has dislocated out of the ulna due to fracturing related to poor residual bone stock.
Cement spacer and multiple antibiotic beads, placed after removal of infected total elbow replacement.