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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 3  |  Issue : 3  |  Page : 57-61

Postoperative infection of elbow joint replacement


1 Department of Orthopaedic Surgery, Hospital of Kanazawa Medical University, Ishikawa, Japan
2 Department of Orthopaedic Surgery, Kanazawa Keiju Hospital, Ishikawa, Japan

Date of Submission10-Jul-2018
Date of Acceptance18-Sep-2018
Date of Web Publication28-Sep-2018

Correspondence Address:
Dr. Ayumi Kaneuji
Department of Orthopaedic Surgery, Hospital of Kanazawa Medical University, 1-1 Daigaku, Uchinada-machi, Kahoku-gun, Ishikawa 920-0293
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ts.ts_8_18

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  Abstract 


Currently, elbow arthroplasty is used to treat elbow joint fracture, tumor, arthritis, and many other elbow-related diseases. However, due to the characteristics of the elbow joint, the success rate of elbow arthroplasty is lower than knee arthroplasty. The most common complication of this surgery is prosthesis infection and loosening. The focus of this case is on prosthesis infection after the elbow arthroplasty surgery.

Keywords: Complication, elbow replacement, infection of the prosthesis


How to cite this article:
Wang X, Fukui K, Yokoyama M, Tsuchiya M, Kaneuji A. Postoperative infection of elbow joint replacement. Transl Surg 2018;3:57-61

How to cite this URL:
Wang X, Fukui K, Yokoyama M, Tsuchiya M, Kaneuji A. Postoperative infection of elbow joint replacement. Transl Surg [serial online] 2018 [cited 2018 Oct 15];3:57-61. Available from: http://www.translsurg.com/text.asp?2018/3/3/57/242493




  Introduction Top


Research status of artificial elbow joint replacement: many medical experts believe that the human body's elbow is one of the most complex joints of all joints.[1] Among the normal functions of the human body, the function of the elbow joint is more important than the wrist joint and shoulder joint. The function of the elbow joint can also affect functions of the shoulder joint and wrist joint. Although elbow joint is nonweight bearing joint, the weight of the upper limb is less than that of the shoulder joint, but the static load of the elbow joint can reach six times of the weight.[2] In clinical, many diseases can influence the elbow joint, the most common one is rheumatoid arthritis, which accounts for 20% to 60% of the elbow joint lesions. At the same time, other lesions include inflammatory joint diseases, such as the primary osteoarthritis, the crystallization of the joint disease, hemophilia, and joint infection.[3] In addition, elbow injuries (mainly trauma), elbow fractures accounted for about 7% of adult fractures, elbow dislocation is ranked second in the joint dislocation, behind the shoulder joint. Therefore, the elbow joint and shoulder joint are more prone to traumatic arthritis.[4] Clinical lesions of elbow joint mainly lead to pain, activity limitation and joint deformity, the effect of upper limb function, reducing of the quality of life.[5] Elbow arthroplasty is a treatment for severely affected elbow joints, which is effective for pain relief and recovery activities. It is a terminal treatment for elderly patients, especially in elderly patients with comminuted humeral fractures and fracture nonunion. Cases achieved satisfactory results.[6]

Worldwide, elbow arthroplasty has been developed for >30 years, and the survival rate of the prosthesis is close to that of total knee arthroplasty.[7] From the perspective of surgical results, most of the functions of elbow arthroplasty were significantly improved, and the pain was significantly relieved.[8],[9] In Japan, the orthopedic research institute believes that the success of elbow joint replacement surgery must achieve elbow joint pain, active stability, joint wear, and tear, and can withstand certain pressure and torsion.[10] However, due to the characteristics of the elbow joint, the incidence of complications of total elbow arthroplasty is higher than total knee arthroplasty.[11] The most common postoperative complications are implant infection, loosening, and dislocation of the prosthesis.[12] In this article, we present cases of infection after total elbow arthroplasty in Japanese hospitals and discuss the complications of total elbow arthroplasty.


  Case Report Top


Ethical committee approval was obtained from Kanazawa Medical University Ethical Committee. The participant was informed about the study and signed the informed consent form. Female, 88-year-old patient. Suffered from the left elbow pain with limited activity in the local hospital for treatment, who had a history of hypertension, high blood lipids and had a bilateral knee replacement surgery. For admission examination results: “O” and the results of an anti-rheumatoid factor, erythrocyte sedimentation rate, C-reactive protein were negative. Slight swelling of the elbow joint, no obvious local tenderness, elastic ring, can touch and more than a hard nodule, elbow joint movement slightly limited, flexion 90°, 10° straight [Figure 1], muscle strength V grade, wrist joint function normal. The narrow gap of the elbow joint and isible joint multiple bone hyperplasia from X film examination.
Figure 1: Preoperative elbow joint X perspective

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Patients in the perfect related underwent artificial elbow joint replacement surgery, according to patient age and characteristics of joint prosthesis, complete removal of intraarticular excess fibrous scar tissue and osteophytosis surgery, proximal humerus and ulna osteotomy and selected supporting prosthesis implantation firmly and postoperative see elbow joint activities of normal [Figure 2]. The patient was advised to avoid large load on her elbow joint and complete scientific exercises for 3 months. Six months after surgery, the patient feels ipsilateral elbow joint discomfort and pain, to the hospital to check found elbow prosthesis ulna end of infection [Figure 3]. Admission underwent elbow prosthesis ulna end removal surgery in the proximal humerus good, ulna end to be implanted steel wire fixed to maintain elbow morphology [Figure 4]a. In patients with a month or so, a trauma, resulting in the elbow prosthesis again, as shown in [Figure 4]b. Operation physicians according to intraoperative findings of the ulna end to end wire, ulna prosthesis removal, reimplantation [Figure 4]c. After about 2 years, again hospitalized patients, at present patients with elbow out visible part of the prosthesis prolapse, and elbow joints can not be normal activities, the loss of part of the function [Figure 5]. Finally, after the discussion of the medical department, decided to remove part of the joint prosthesis, control of infection, treatment of osteoporosis treatment, surgical removal of the humerus part of the humerus [Figure 6]. Take the current exclusion treatment, elbow joint function to maintain fixed branch. After the film is shown [Figure 7].
Figure 2: After the first elbow surgery

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Figure 3: Medical examination half 1 year postoperative

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Figure 4: Development of the elbow joint after surgery. X-ray of the elbow joint (a). X-ray after dislocation of elbow joint (b). X-ray after elbow joint prosthesis fracture (c)

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Figure 5: After 2 years, patients with elbow out visible part of the prosthesis prolapse, and elbow joints cannot be normal activities

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Figure 6: Founding during surgery

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Figure 7: After the last surgery, the patient's elbow joint

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  Discussion Top


From this case, we can see that patients underwent the initial total elbow arthroplasty, after repeated postoperative infection, prosthesis loosening, dislocation, and then infection, two fractures, and so on. After repeated operations the result is not satisfactory, as the patient has lost the function of the elbow joint, reducing the patient's quality of life.

Infection can be divided into early and late infection after joint replacement.[13],[14] Early infection is related to the operation, and the incidence of infections can be reduced by strictly regulating the operation technique, shortening the operation time (reducing the exposure time of the patients), the wound healing and postoperative wound drainage, and the use of antibiotics before and after the operation. If infection occurs, adequate drainage and irrigation should be performed as soon as possible.[15] Prevention of infection is obviously an important consideration. A thorough history and physical examination to identify sources of potential infection, such as infected diabetic foot ulcers, is paramount before undergoing any arthroplasty surgery. Furthermore, a recent advisory statement provided by the American Academy of Orthopaedic Surgeons discussed routine prophylaxis with Keflex, amoxicillin, or clindamycin (if penicillin allergic) for 2 years following before various procedures, such as dental cleaning.[3] RJoint replacement surgery routine prophylaxis after joint replacement surgery 2 years following may be also considered in some patients who have immune suppression due to certain medical conditions or immunosuppressive medications. Finally, adding prophylactic antibiotics to cemented arthroplasties has been advocated, especially in revision surgery. In China, a lot of experience of the surgeon suggested that if determine the postoperative infection and feasible wound sustained infusion of antibiotics when necessary clear necrotic tissue of the wound. Pseudomonas, Klebsiella, and  Escherichia More Details coli. Occasionally, mixed infections with anaerobes such as Enterococcus and Peptococcus are present. Finally, fungal infections such as Mycobacterium tuberculosis and Candida albicans are infrequent but may be present, especially in the immune compromised host. An important consideration with regard to etiology is the virulence of the organism. Previous investigators have cited increased difficulty with the eradication of certain bacteria. Some authors have proposed differing treatment recommendations depending on which microorganism(s) are present. In an early, often cited publication, someone reported results with single staged resection and reimplantation hip arthroplasty and found that Gram-negatives including Klebsiella, Proteus, and Pseudomonas groups were associated with a high rate of failure. In this study, it was found that approximately 50% of these Gram-negative infections failed treatment. However, these results must be viewed cautiously, since many patients in this study did not receive intravenous antibiotics postoperatively, which is the current standard of care. A few small series in the literature have shown reduced efficiency in treating specific organisms such as coagulase positive Staphylococcus, and certain Gram-negatives. However, due to the lack of solid evidence-based medicine, the decision to retain versus remove the implant should not be based primarily on the specific type of bacteria encountered, but rather on the duration of symptoms.[16],[17],[18],[19],[20]


  Conclusions Top


The relevant literature was informed that the cause of infection was mainly: (1) patients with other basic diseases, such as diabetes, pulmonary infection, hypertension, and so on, these factors are considered to increase the probability of infection after surgery.[17] Therefore, perioperative preparation is particularly important, preoperative preparation should be sufficient to minimize postoperative wound infection; (2) operation time: the shorter the operation time, the less bacterial growth of the wound, exposure to antibiotics, reducing unnecessary injuries, and reduce the incidence of postoperative complications.[18],[19] (3) A large number of foreign literature reports show that high-level laminar flow operation room joint replacement surgery can significantly reduce the incidence of postoperative infection; the patient's surgery will also affect postoperative wound healing.[20] (4) The application of antibiotics: the use of prophylactic antibiotics, the inhibition of these bacteria.[21] Classifying infection into acute versus late infection aids in the treatment plan. For acute infections presenting within 2–4 weeks of symptom onset, irrigation, and debridement with polyethylene liner exchange and retention of components may be possible. When attempting component retention, thorough debridement and rapid treatment of the infection before the accumulation of any biofilm is paramount for a successful outcome. Other important prognostic factors include the virulence of the microorganism as well as the immune status of the host. Despite expeditious management, irrigation and debridement of acute total hip and knee infections frequently lead to recurrent infection. Thus, patients should be counseled accordingly. Further management may be needed following an initial attempt at component retention. These options include resection arthroplasty with or without re-implantation, long-term antibiotic suppressive therapy, arthrodesis and even above the knee amputation in rare circumstances. For chronic infections, a successful outcome depends on several factors including the baseline health status of the patient, implant removal with a thorough debridement followed by culture-specific antibiotic treatment. Furthermore, methods of monitoring for persistent infection include following laboratory values such as the C-reactive protein, erythrocyte sedimentation rate, and cultures from joint aspirations. Whether to perform a direct exchange versus a delayed revision arthroplasty for chronic total hip and knee infections can be debated. Several published series have reported successful outcomes with single stage procedures when patients are carefully selected. However, the majority of chronic infections in the United States are treated with two-stage resection, since this method has consistently provided the highest cure rates, with many current studies demonstrating 90% success. However, longer operation time and greater surgical exposure increased the risk of contamination. However, the use of prophylactic antibiotics is still the only effective method to prevent postoperative infection. Prophylactic use of antibiotics is generally 48 h before the operation and use of antibiotics.[22] At the same time, surgeons should also pay attention to operation and strict aseptic concept. Antibiotics are used to ensure a local drug concentration and to reach an effective level in operation.[23]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Linn MS, Gardner MJ, McAndrew CM, Gallagher B, Ricci WM. Is primary total elbow arthroplasty safe for the treatment of open intra-articular distal humerus fractures? Injury 2014;45 (11):1747-51.  Back to cited text no. 1
    
2.
Prasad N, Ali A, Stanley D. Total elbow arthroplasty for non-rheumatoid patients with a fracture of the distal humerus: A minimum ten-year follow-up. Bone Joint J 2016;98-B (3):381-6.  Back to cited text no. 2
    
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Torrens C, Guirro P, Miquel J, Santana F. Influence of glenosphere size on the development of scapular notching: A prospective randomized study. J Shoulder Elbow Surg 2016;25 (11):1735-41.  Back to cited text no. 3
    
4.
Williams H, Madhusudhan T, Sinha A. Mid-term outcome of total elbow replacement for rheumatoid arthritis. J Orthop Surg (Hong Kong) 2016;24 (2):262-4.  Back to cited text no. 4
    
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Prasad N, Dent C. Outcome of total elbow replacement for distal humeral fractures in the elderly: A comparison of primary surgery and surgery after failed internal fixation or conservative treatment. J Bone Joint Surg Br 2008;90 (3):343-8.  Back to cited text no. 5
    
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Garcia JA, Mykula R, Stanley D. Complex fractures of the distal humerus in the elderly. The role of total elbow replacement as primary treatment. J Bone Joint Surg Br 2002;84 (6):812-6.  Back to cited text no. 6
    
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Van der lugt JC, Geskus RB, Rozing PM. Primary Souter-Strath-Clyde total elbo prosthesisin rheumatoidarthritis. J Bone Joint Surg Am 2005;87 Suppl 1(Pt 1):67-77.  Back to cited text no. 7
    
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Schmidt-Horlohé K, Buschbeck S, Wincheringer D, Weißenberger M, Hoffmann R. Primary radial head arthroplasty in trauma: Complications. Orthopade 2016;45 (10):853-60.  Back to cited text no. 8
    
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Kooistra BW, Willems WJ, Lemmens E, Hartel BP, van den Bekerom MP, van Deurzen DF. Comparative study of total shoulder arthroplasty versus total shoulder surface replacement for glenohumeral osteoarthritis with minimum 2-year follow-up. J Shoulder Elbow Surg 2016;26 (3):430-6.  Back to cited text no. 10
    
11.
Mannan S, Ali M, Mazur L, Chin M, Fadulelmola A. The use of tranexamic acid in total elbow replacement to reduce post-operative wound infection. J Bone Jt Infect 2018;3 (2):104-7.  Back to cited text no. 11
    
12.
Lovy AJ, Keswani A, Koehler SM, Kim J, Hausman M. Short-term complications of distal humerus fractures in elderly patients: Open reduction internal fixation versus total elbow arthroplasty. Geriatr Orthop Surg Rehabil 2016;7 (1):39-44.  Back to cited text no. 12
    
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Kumar S1, Mahanta S. Primary total elbow arthroplasty. Indian J Orthop 2013;47 (6):608-14.  Back to cited text no. 13
    
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Kodde IF, Heijink A, Kaas L, Mulder PG, van Dijk CN, Eygendaal D. Press-fit bipolar radial head arthroplasty, midterm results. J Shoulder Elbow Surg 2016;25 (8):1235-42.  Back to cited text no. 14
    
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Uri O, Bayley I, Lambert S. Hip-inspired implant for revision of failed reverse shoulder arthroplasty with severe glenoid bone loss. Improved clinical outcome in 11 patients at 3-year follow-up. Acta Orthopaedica 2014;85 (2):171-6.  Back to cited text no. 17
    
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Jenkins PJ, Watts AC, Norwood T, Duckworth AD, Rymaszewski LA, Eachan JE. Total elbow replacement: Outcome of 1,146 arthroplasties from the Scottish Arthroplasty Project. Acta Orthop 2013;84 (2):119-23.  Back to cited text no. 18
    
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Suda AJ, Kommerell M, Geiss HK, Burckhardt I, Zimmermann S, Zeifang F, Lehner B. Prosthetic infection: Improvement of diagnostic proceduresusing 16S ribosomal deoxyribonucleic acid polymerase chain reaction. Int Orthop 2013;37 (12):2515-21.  Back to cited text no. 19
    
20.
Plaschke HC, Thillemann T, Belling-Sørensen AK, Olsen B. Revision total elbow arthroplasty with the linked Coonrad-Morrey total elbow arthroplasty: A retrospective study of twenty procedures. Int Orthop 2013;37 (5):853-8.  Back to cited text no. 20
    
21.
Scarlat MM. Complications with reverse total shoulder arthroplasty and recent evolutions. Int Orthop 2013;37 (5):843-51.  Back to cited text no. 21
    
22.
Maheshwari R, Vaziri S, Helm RH. Total elbow replacement with the Coonrad-Morrey prosthesis: Our medium to long-term results. Ann R Coll Surg Engl 2012;94 (3):189-92.  Back to cited text no. 22
    
23.
Portillo ME, Salvadó M, Alier A, Sorli L, Martínez S, Horcajada JP, Puig L. Prosthesis failure within 2 years of implantation is highly predictive of infection. Clin Orthop Relat Res 2013;471 (11):3672-8.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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