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Management of Periprosthetic Fractures
Multiple studies have shown that 5% to 36% of primary TEAs are complicated by periprosthetic fractures intraoperatively or postoperatively. In a recent prospective study, the use of a total elbow prosthesis that mimics the anatomic characteristics and kinematics of the elbow joint resulted in periprosthetic fracture in 7% of primary surgeries and 8% of revisions. Intraoperative fractures occur during bone preparation (such as a cortical breach during reaming), during implantation, or as the result of torsional forces on the bone during limb positioning. Displaced humeral condyle fractures can be excised and the soft-tissue envelope repaired to the triceps fascia. Intraoperative fractures of the olecranon should be fixed to secure the integrity of the extensor mechanism. Meticulous preoperative planning is imperative for the management of periprosthetic elbow fractures. The prostheses, equipment, and bone graft materials used are not readily available in most hospitals and must be ordered in advance. The surgeon should identify the type of prosthesis implanted during previous surgery and the exact year in which it was implanted. Implant designs have changed, and different generations of specific linkage mechanisms exist. Each implant system has unique nuances and limitations, such as the coupling mechanisms, and these must be understood before surgery. If an unlinked prosthesis was implanted originally, then the anatomic requirements for stability must be well understood. Bone loss may preclude the use of an unlinked implant in the revision setting, and the surgeon must be prepared to revise the implant completely to a linked design. If this is the case, then the surgeon should be experienced in implant extraction with bone preservation techniques, such as the use of osteotomies. This chapter reviews surgical strategies for managing periprosthetic fractures about the elbow. Indications and contraindications are discussed, and technical aspects of fracture fixation, implant revision, and preserving periprosthetic bone stock are presented. Tips for avoiding complications such as nerve injury and infection are also reviewed.