What happens when removing hardware from an infected elbow?

From the Guidelines

When hardware removal is necessary from an infected elbow, the procedure typically involves surgical intervention to extract the implants while simultaneously addressing the infection, with the goal of eradicating the infection and maintaining joint function and quality of life 1. The surgical approach for managing treatment failure in prosthetic joint infection, including infected elbow hardware, involves several options, including debridement and implant retention, prosthesis exchange, prosthesis resection, or amputation 1.

• The optimal aims of therapy for prosthetic joint infection are to eradicate the infection and to maintain function of the joint and quality of life for the patient 1.
• Surgical options, such as debridement and implant retention, prosthesis exchange, or prosthesis resection, are considered based on factors like patient comorbidities, age of the prosthesis, duration of symptoms, quality of the soft tissues and bone stock, causative microorganism, and patient wishes 1.
• Debridement without removal of the infected prosthesis can be done, but it is typically reserved for patients with a well-fixed prosthesis with early postoperative infection or patients with short duration of symptoms in hematogenous infection 1.
• Staged exchange or 2-stage exchange is most often used for the treatment of chronic prosthetic joint infection associated with prosthesis loosening, involving removal of all infected prosthetic components and cement, followed by debridement of infected periprosthetic tissue, and reimplantation of a new prosthesis after an interval of antimicrobial treatment 1.
• The use of antimicrobial-impregnated cement and devices is common in the treatment of prosthetic joint infection, and the clinician should be aware of the potential for systemic toxicity of local antimicrobial delivery devices 1.
• The period of time between resection arthroplasty and re-implantation can be used to evaluate for residual infection by clinical assessment and laboratory tests, as well as intraoperative inspection and pathologic review of the periprosthetic tissue at the time of reimplantation 1. The most recent and highest quality study recommends a staged exchange or 2-stage exchange approach for the treatment of chronic prosthetic joint infection, with a success rate of 87% 1.

From the Research

Removal of Hardware from Infected Elbow

• The removal of hardware from an infected elbow is a complex procedure that requires careful consideration of the patient's overall health and the severity of the infection 2, 3.
• Studies have shown that the management of infected total elbow arthroplasty using a two-stage revision can result in high rates of eradication, although rates of reoperation and transient ulnar nerve dysfunction are high 2.
• The commonest infecting organism in cases of infected elbow arthroplasty is Staphylococcus aureus, which can be treated with antibiotics such as ceftriaxone 2, 4.
• The removal of titanium hardware from the elbow can be problematic, especially if it is done late after implantation, as it can result in screw failure during extraction 5.
• Factors that can influence the success of hardware removal include the type of metal used, the duration of implantation, and the location of the screws around the elbow 5.

Complications and Considerations

• Patients who undergo hardware removal from an infected elbow may experience complications such as ulnar nerve dysfunction, which can resolve fully without further treatment 2.
• The use of antibiotic-lock therapy, such as vancomycin, can be effective in treating infections and reducing the need for catheter removal 6.
• The management of infected total elbow arthroplasty requires a comprehensive approach that takes into account the patient's overall health, the severity of the infection, and the potential risks and complications of treatment 2, 3.