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Modes of Wear After Semiconstrained Total Elbow Arthroplasty

¹ Department of Orthopedic Surgery, Rush University Medical Center, 1653 West Congress Parkway, Chicago, IL 60612. E-mail address for R.M. Urban: robert_urban{at}rush.edu
² Hand and Upper Limb Center, St. Joseph's Health Care, University of Western Ontario, 268 Grosvenor Street, London, ON N6A 4L6, Canada
³ Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Medical Sciences Building 3-69, Rochester, MN 55905

Investigation performed at the Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Institutes of Health (Grant AR39310), Zimmer (Warsaw, Indiana), and a Mid-America Orthopaedic Association Multipurpose Resident Grant. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Tournier). Also, commercial entities (Applied Spine Technologies, DePuy, Medtronic, SpinalMotion, Smith and Nephew, Wright Medical, Zimmer, and Stryker) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.

Methods: Semiconstrained total elbow arthroplasty components were retrieved from sixteen elbows (fourteen patients) at either revision surgery (at a mean of five years after implantation) for mechanical failure (fifteen elbows) or postmortem examination (one elbow). In all cases, the retrieved implant was the primary implant. The patterns of damage on these components were investigated with stereomicroscopy in correlation with clinical findings, serial radiographs, and histopathological observations.

Results: All of the retrieved devices exhibited multiple modes of wear. Damage to the humeral and ulnar polyethylene bushings was nearly universal; twenty-seven of twenty-eight humeral bushings demonstrated asymmetrical thinning, while fifteen of sixteen ulnar bushings demonstrated elliptical plastic deformation. In addition, unintended metal-on-metal wear between bearing and nonbearing surfaces or between two nonbearing surfaces was commonly observed, typically in association with wear and deformation of the polyethylene bushings. Wear between the stem and the cement mantle was observed in most of the ulnar components. The histopathology of the periprosthetic tissues was similar in character to that observed in association with osteolysis and loosening of total hip and knee replacements, while analysis of the particulate debris revealed a preponderance of titanium alloy and polyethylene debris. Barium sulfate particles were also observed to a lesser extent.

Conclusions: Multimodal wear in total elbow replacements can lead to osteolysis, aseptic loosening, and prosthetic and periprosthetic fracture necessitating revision surgery. Polyethylene wear and damage, as well as unintended metal-on-metal wear, contribute to the periprosthetic particulate burden, which is likely pathogenic in these processes.

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