Dear List Members.
I apologize for not writing sooner. A few of you have asked me to post the
responses to my Question about treating a failed elbow replacement. I’ve
been a bit distracted by other issues and didn’t get to posting sooner.
So, to recap, the question was this. I have a family member who underwent
elbow replacement surgery. The surgery became infected and the replacement
was removed. According to the surgeon a second replacement is not
possible.I asked for treatment recommendations and stories of success or
failure with past experiences.
Although the responses were mixed most tended toward recommending custom
made braces.
Here are some of the responses…
I am not sure what you mean by a “spacer” but, I had a case years ago with
a woman who had her elbow prosthesis removed due to infection.
There was no stability at the elbow and when she contracted her biceps, the
arm shortened as the forearm was pulled toward the shoulder.
The only way to maintain the length of her arm was to keep a distally
directed force at the wrist. This was difficult to maintain without causing
breakdown of the skin at the wrist.
The brace that she did best with was a custom, double-upright elbow brace
with molded leather cuffs that were well padded.
Hey Jack, I have a similar patient that I have been working with for many
years now. She has no elbow joint and is manifest much like a non union.
Over the years we have tried several different styles/materials for her
from custom polyeth. to off shelf design single and double upright. She has
been most comfortable in softer material and a double upright design
supports best. She continues to use the RCAI BAB style over any other that
we have provided for her. We lock the elbow ROM joint at optimal position
for her functionality (hers is 75*). She does not tolerate the plastic
designs, although it would last longer, maybe because of the heat in the
south summer time.
I believe a few years ago I saw a patient with similar condition, used
custom Townsend brace, holds the elbow very well.
I had a patient that came to see me for an AFO but also had an elbow
replacement gone awry. We discussed his elbow for a while. According to
him they tried the second replacement but it was promptly removed, leaving
him with essentially a flail arm. He had full muscle control of the arm and
hand but it wasn’t functional because of the elbow joint issue. He had a
postop ROM device that he used in the short term but abandoned it due to
difficulty donning. He considered amputation but declined because his hand
was fully functional and he was older and didn’t want to have to deal with
learning how to use a prosthesis. My suggestion was a modified fracture
SEW Ox. He never pursued it as he had his routine and had other more
pressing issues.
This same problem happened to a patient I saw more than 20 years ago. We
casted the other side and used these dimensions for a starting point.
Maintaining length will be key to her ability to use the arm after some
minor mods to the cast we pulled it out of 2mil PE and cut off hot and
inverted it inside out. Probable now CAD would be the way to go. Standard
knee joints worked fine though we adjusted the AP offset in the bars and
prevent full ext. Trial and error finally determined pressure areas with
the final being pretty much TSB.
I would most definitely go custom. I wouldn’t even bother opening a book
to consider anything OTS.
I had a 90 year old female patient with a failed elbow replacement. I used
the Orthoamerica Prime Elbow System with moderate success. Her musculature
and skin were very soft and fragile, which led to associated problems with
pressure skin breakdown even with a Aliplast interface. However, it did
reduce the strain and rotation at the elbow joint.
Personally, I love the idea of casting the contralateral arm. I had been
thinking about how to deal with casting such a sensative situation and
hadn’t thought of that option.
I also received a few recommendations of doctors for a second opinion. I
will provide those privately if anyone is in need.
Anyway, Thanks again to everybody for the great advice, I apologize if I
left anything out.
Jack Ben-Ezra, CP, BOCO
