J Shoulder Elbow Surg (2015) 24, e144-e147
www.elsevier.com/locate/ymse
Reconstruction of massive bone loss in the elbow using vascularized fibular transfer: a case report Manuel Zafra, MD, PhDa,*, Pilar Uceda, MDb, Rocıo Carpintero, MDb a b
Instituto de Traumatologıa Cordobes, C ordoba, Spain Department of Orthopedic Surgery, Hospital Universitario Reina Sofıa, Cordoba, Spain
The unfavorable progress of certain serious cases may require resection of necrosed, devitalized, and infected bone, leading to floating joints and considerable bone loss. Possible treatment options include (1) arthrodesis, which is hindered by bone loss; (2) an allograft/autograft prosthesis composite,1,10,12 which carries a high risk of reactivating infection and, in young patients, an equally high risk of prosthetic loosening; and, (3) less commonly, autologous reconstruction of these injuries, as described in anecdotal case reports2,7. Interposition arthroplasty has been used successfully to avoid prosthetic replacement in young patients with elbow arthritis in which the osseous anatomy of the joint is preserved.6,11 This case report presents a 39-year-old man with floating elbow after infection of a complex open fracture, with loss of the distal portion of the humerus. He underwent interposition arthroplasty in which bone anatomy was reconstructed by a vascularized fibular transfer. This report describes the surgical technique and reports the functional outcome after a 20-month follow-up.
Case report A 39-year-old man was admitted to the Accident and Emergency Unit after a motorcycle accident having susThis study was approved by the Ethical Committee of the Hospital de la Cruz Roja de C ordoba, Spain. *Reprint requests: Manuel Zafra, MD, PhD, Capellan Miguel Orti St, Number 3, E-14011 C ordoba, Spain. E-mail address: [email protected] (M. Zafra).
tained a grade II complex open supraintercondylar fracture of the left elbow (Fig. 1). The emergency surgery included placement of an external fixator, minimal fixation of bone fragments using Kirschner wires, debridement, and wound closure. Intravenous antibiotics were administered for 1 week. The patient had multiple infections that were treated with intravenous antibiotic and surgical cleansing and debridement. Eight months after the accident, C-reactive protein was 0.7 mg/L and the erythrocyte sedimentation rate was 8 mm/h. Figure 2 shows a bone deficit in the distal third of the humerus that was more than 6 cm, resulting in a floating elbow. In view of a number of factors, including the previous long and complex infectious process, the extent of bone loss, and the patient’s age, the decision was made to reconstruct the elbow joint using interposition arthroplasty with a vascularized fibular transfer. The posterior incision of the elbow was enlarged to expose the middle third of the arm, and the anterior incision was enlarged as far as the middle third of the forearm to facilitate dissection of the radial artery pedicle. The posterior approach involved an extensile triceps-sparing exposure. Radial and ulnar nerves were identified and referenced. One centimeter of the end of the humerus was resected. A vascularized bone graft measuring approximately 18 cm was taken from the contralateral leg. After osteoclasis, taking special care to keep periosteal hinge to avoid damaging the vascularization, a graft was created in the form of an isosceles triangle with a base of approximately 5 cm and sides of approximately 7 cm (Fig. 3). With the
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2015.01.010
Massive bone loss in elbow
e145
Figure 1 Initial postaccident radiograph shows a highly comminuted open supraintercondylar fracture of the elbow.
Figure 3 Vascularized fibular transfer after double osteoclasis, before implantation in the elbow.
Figure 2 Seven months later, after a number of operations, the whole distal portion of the humerus (approximately 6 cm) was resected.
peroneal and tibial muscles inserted to interposition, the graft was placed at the distal end of the humerus and held in position with 2 dynamic compression plates. The elbow joint was then reduced, achieving articular coaptation and interposition of muscle tissue between the graft and the ulna. The peroneal artery was sutured to the radial artery, which required looking for it 3 cm distal to the elbow to get a correct suture without stress. We then divided it and performed a suture end-to-end, and the fibular vein to the superficial cephalic vein of the forearm. We checked the integrity of the suture, removing the ischemia and observing graft bleeding and the continuity of the suture. The triceps was reattached to the olecranon using transosseous stitches. The soft tissues containing the internal and external lateral ligaments of the elbow were fixed laterally. Finally, an external fixator was positioned to maintain elbow reduction and distraction at 90 flexion (Fig. 4).
Figure 4 An external elbow fixator was placed to maintain joint reduction and distraction and aid subsequent healing of lateral ligaments.
Vascular patency was monitored preoperatively by external Doppler every 12 hours for 2 days and then every 24 hours for 3 days. The external fixator was retained for 3 months. Rehabilitation then commenced with elbow flexion/extension and forearm prosupination. Figure 5, A and B demonstrates the patient at 12 months postsurgery. Range of motion of the elbow in flexion/ extension was 105 to 35 and prosupination of the forearm was 80 to 80 . Clinically, the patient reported no pain, and the elbow was stable. Radiography confirmed the consolidation of the fibular graft to the humerus (Fig. 6, A and B). At 20 months postsurgery, the patient was subjectively highly satisfied and clinically retained movement and stability of the elbow.
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Figure 5
Range of motion for elbow (A) flexion and (B) extension at 12 months postsurgery.
Figure 6
(A) Lateral and (B) anteroposterior radiographs at 12 months postsurgery.
Discussion Infection is one of the worst complications of open joint fractures. Unfavorable progress due to concomitant factors, such as the virulence of the microorganism involved, the presence of soft-tissue damage, and devascularization and necrosis of bone, may lead to joint destruction with bone loss presenting a challenge for treatment. Associated factors, including patient age and the functionality of the joint for daily domestic and professional life, should be taken into account when deciding on the treatment strategy. Here, an infected fracture requiring various operations, leading eventually to floating elbow in the nondominant arm of a 39-year-old man, prompted consideration of a range of treatment options, examined below. Elbow arthrodesis9 in various positions is recommended in the literature for infections and defects that cannot be managed by prosthesis implantation or other methods. Another option is joint reconstruction using a fresh frozen allograft. Dean et al4 reported in 1997 a group of 23 patients who underwent elbow allograft reconstruction, with varying results and a high complication rate. Use of a conventional prosthesis is another option, although there is a danger of instability and possible loosening: simple, rigid types of prostheses are known to lead to premature loosening.8,13 Patient age is a key factor: Celli and Morrey3 report revision rates of 22% within the first
91 months for patients receiving an elbow replacement before the age of 40. Here, massive bone loss suggested the possibility of a custom-made prosthesis5, although such prostheses, due to being constrained, are associated with higher rates of loosening. A further option was an allograftprosthetic composite.1,10 Morrey et al,12 in a study of 25 patients undergoing revision total arthroplasty using an allograft prosthetic composite, reported a revision rate of 38% and a high rate of complications, leading to 33% failure in case of surgery for infection. The last option was elbow interposition arthroplasty, reportedly a viable approach for elbow arthritis in patients too young to be candidates for a prosthetic joint replacement.6,11 This technique preserves the basic anatomy of the elbow, but where there is irreparable damage to the cartilage, interposition of soft tissuedgenerally tendinousdfrom the joint surface provides an acceptable range of movement and causes little pain, achieving good results in the medium-term to long-term. In our patient, however, bone loss was so great that reconstruction using a vascularized bone graft with the functionality of an interposition arthroplasty was deemed to be the best strategy. Vascularized bone transfers have been successfully used on a number of occasions. Hattori et al7 reported the use of vascularized iliac bone graft for reconstruction of massive bone defect of the distal humerus, with good results. More recently, Cavadas et al2 described use of vascularized iliac crest or fibular osteocutaneous grafts to reconstruct massive
Massive bone loss in elbow bone loss in 5 patients aged younger than 40 years. Mean follow-up was 22 months, mean range of motion was 86 , patients reported no significant pain, and lateral stability was acceptable. External fixation was maintained for 4 weeks, and secondary reconstruction of lateral ligaments was performed 6 to 8 weeks later using an autologous tendon graft. Here, the treatment of choice for reconstruction of bone defect was interposition arthroplasty using a vascularized fibular transfer. The choice was governed by 3 major considerations: (1) floating elbow caused by a complex open fracture that subsequently became infected by aggressive microorganisms, requiring several operations; (2) significant bone loss, involving approximately 6 cm of the distal third of the humerus; and (3) patient age. Use of a vascularized fibular transfer with periosteum and some muscle tissue interpositioned in the bone enabled the anatomy of the distal portion of the humerus to be reconstructed and was functionally comparable to the interposition of soft tissue in classical interpositional arthroplasty. Use of a vascular graft avoided bone resorption, and the mediumterm and long-term outcome was promising. Dynamic compression plates and minimal osteosynthesis were used in view of the risk of reactivation of infection. External ligaments were released and then reattached to the vascularized graft. An external distraction fixator was left in place for 3 months to aid consolidation of the fibular graft osteoclasis and ensure elbow stability, with no need for secondary lateral-ligament surgery. Clinical results and elbow stability were good, as was medium-term patient satisfaction. Although no clinical or radiographic deterioration was apparent after 20 months of follow-up, a longer period is required to better define the long-term fate of this autologous reconstruction. However, should this technique fail in the future, other viable options remain, including replacement arthroplasty or arthrodesis.
Conclusions Infection is a major potential complication of open joint fracture. Unfavorable progress may lead to extensive bone loss, seriously hampering treatment. In this case study, a 39-year-old man who had undergone surgery on several occasions for an infected open fracture presented with floating elbow accompanied by the loss of approximately 6 cm of bone from the distal humerus. Possible treatment options, given the extent of joint involvement, were arthrodesis, allograft-prosthetic composite, or interposition arthroplasty with vascularized bone. Interposition arthroplasty using a vascularized fibular bone graft was the treatment chosen. A good functional outcome was apparent after a limited
e147 20-month follow-up, and the patient was highly satisfied with the result.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Amirfeyz R, Stanley D. Allograft-prosthesis composite reconstruction for the management of failed elbow replacement with massive structural bone loss: a medium-term follow-up. J Bone Joint Surg Br 2011; 93:1382-8. http://dx.doi.org/10.1302/0301-620X.93B10.26729 2. Cavadas PC, Landi L, Thione A, Iba~nez J, Nthumba P, Roger I. Reconstruction of massive bone losses of the elbow with vascularized bone transfers. Plast Reconstr Surg 2010;126:964-72. http://dx.doi. org/10.1097/PRS.0b013e3181e6b0b9 3. Celli A, Morrey BF. Total elbow arthroplasty in patients forty years of age or less. J Bone Joint Surg Am 2009;91:1414-8. http://dx.doi.org/ 10.2106/JBJS.G.00329 4. Dean GS, Holliger EH, Urbaniak JR. Elbow allograft for reconstruction of the elbow with massive bone loss. Long term results. Clin Orthop Relat Res 1997;341:12-22. 5. Franke A, Bieler D, Hentsch S, Johann M, Kollig E. Reconstruction of an elbow joint after blast injury by arthroplasty with a custom-made modified total elbow prosthesis: a case report. J Shoulder Elbow Surg 2014;23:e81-7. http://dx.doi.org/10.1016/j.jse.2014.01.013 6. Froimson AI, Silva JE, Richey DG. Cutis arthroplasty of the elbow joint. J Bone Joint Surg Am 1976;58:863-5. 7. Hattori Y, Doi K, Pagsaligan JM, Takka S, Ikeda K. Vascularized iliac bone graft for reconstruction of massive bone defect of the distal humerus. J Reconstr Microsurg 2005;21:287-91. http://dx.doi.org/10. 1055/s-2005-871768 8. Kim JM, Mudgal CS, Konopka JK, Jupiter JB. Complications of total elbow arthroplasty. J Am Acad Orthop Surg 2011;19:328-39. 9. Koller H, Kolb K, Assuncao A, Kolb W, Holz U. The fate of elbow arthrodesis: indications, techniques and outcome in fourteen patients. J Shoulder Elbow Surg 2008;17:293-306. http://dx.doi.org/10.1016/j. jse.2007.06.008 10. Mansat P, Adams RA, Morrey BF. Allograft-prothesis composite for revision of catastrophic failure of total elbow arthroplasty. J Bone Joint Surg Am 2004;86:724-35. 11. Morrey BF. Distraction arthroplasty: clinical applications. Clin Orthop Relat Res 1993;293:46-54. 12. Morrey ME, Sanchez-Sotelo J, Abdel MP, Morrey BF. AllograftProsthetic composite reconstruction for massive bone loss including catastrophic failure in total elbow arthroplasty. J Bone Joint Surg Am 2013;95:1117-24. http://dx.doi.org/10.2106/JBJS.L.00747 13. Voloshin I, Schippert DW, Kakar S, Kaye EK, Morrey BF. Complications of total elbow replacement: a systematic review. J Shoulder Elbow Surg 2011;20:158-68. http://dx.doi.org/10.1016/j.jse. 2010.08.026
www.elsevier.com/locate/ymse
Reconstruction of massive bone loss in the elbow using vascularized fibular transfer: a case report Manuel Zafra, MD, PhDa,*, Pilar Uceda, MDb, Rocıo Carpintero, MDb a b
Instituto de Traumatologıa Cordobes, C ordoba, Spain Department of Orthopedic Surgery, Hospital Universitario Reina Sofıa, Cordoba, Spain
The unfavorable progress of certain serious cases may require resection of necrosed, devitalized, and infected bone, leading to floating joints and considerable bone loss. Possible treatment options include (1) arthrodesis, which is hindered by bone loss; (2) an allograft/autograft prosthesis composite,1,10,12 which carries a high risk of reactivating infection and, in young patients, an equally high risk of prosthetic loosening; and, (3) less commonly, autologous reconstruction of these injuries, as described in anecdotal case reports2,7. Interposition arthroplasty has been used successfully to avoid prosthetic replacement in young patients with elbow arthritis in which the osseous anatomy of the joint is preserved.6,11 This case report presents a 39-year-old man with floating elbow after infection of a complex open fracture, with loss of the distal portion of the humerus. He underwent interposition arthroplasty in which bone anatomy was reconstructed by a vascularized fibular transfer. This report describes the surgical technique and reports the functional outcome after a 20-month follow-up.
Case report A 39-year-old man was admitted to the Accident and Emergency Unit after a motorcycle accident having susThis study was approved by the Ethical Committee of the Hospital de la Cruz Roja de C ordoba, Spain. *Reprint requests: Manuel Zafra, MD, PhD, Capellan Miguel Orti St, Number 3, E-14011 C ordoba, Spain. E-mail address: [email protected] (M. Zafra).
tained a grade II complex open supraintercondylar fracture of the left elbow (Fig. 1). The emergency surgery included placement of an external fixator, minimal fixation of bone fragments using Kirschner wires, debridement, and wound closure. Intravenous antibiotics were administered for 1 week. The patient had multiple infections that were treated with intravenous antibiotic and surgical cleansing and debridement. Eight months after the accident, C-reactive protein was 0.7 mg/L and the erythrocyte sedimentation rate was 8 mm/h. Figure 2 shows a bone deficit in the distal third of the humerus that was more than 6 cm, resulting in a floating elbow. In view of a number of factors, including the previous long and complex infectious process, the extent of bone loss, and the patient’s age, the decision was made to reconstruct the elbow joint using interposition arthroplasty with a vascularized fibular transfer. The posterior incision of the elbow was enlarged to expose the middle third of the arm, and the anterior incision was enlarged as far as the middle third of the forearm to facilitate dissection of the radial artery pedicle. The posterior approach involved an extensile triceps-sparing exposure. Radial and ulnar nerves were identified and referenced. One centimeter of the end of the humerus was resected. A vascularized bone graft measuring approximately 18 cm was taken from the contralateral leg. After osteoclasis, taking special care to keep periosteal hinge to avoid damaging the vascularization, a graft was created in the form of an isosceles triangle with a base of approximately 5 cm and sides of approximately 7 cm (Fig. 3). With the
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2015.01.010
Massive bone loss in elbow
e145
Figure 1 Initial postaccident radiograph shows a highly comminuted open supraintercondylar fracture of the elbow.
Figure 3 Vascularized fibular transfer after double osteoclasis, before implantation in the elbow.
Figure 2 Seven months later, after a number of operations, the whole distal portion of the humerus (approximately 6 cm) was resected.
peroneal and tibial muscles inserted to interposition, the graft was placed at the distal end of the humerus and held in position with 2 dynamic compression plates. The elbow joint was then reduced, achieving articular coaptation and interposition of muscle tissue between the graft and the ulna. The peroneal artery was sutured to the radial artery, which required looking for it 3 cm distal to the elbow to get a correct suture without stress. We then divided it and performed a suture end-to-end, and the fibular vein to the superficial cephalic vein of the forearm. We checked the integrity of the suture, removing the ischemia and observing graft bleeding and the continuity of the suture. The triceps was reattached to the olecranon using transosseous stitches. The soft tissues containing the internal and external lateral ligaments of the elbow were fixed laterally. Finally, an external fixator was positioned to maintain elbow reduction and distraction at 90 flexion (Fig. 4).
Figure 4 An external elbow fixator was placed to maintain joint reduction and distraction and aid subsequent healing of lateral ligaments.
Vascular patency was monitored preoperatively by external Doppler every 12 hours for 2 days and then every 24 hours for 3 days. The external fixator was retained for 3 months. Rehabilitation then commenced with elbow flexion/extension and forearm prosupination. Figure 5, A and B demonstrates the patient at 12 months postsurgery. Range of motion of the elbow in flexion/ extension was 105 to 35 and prosupination of the forearm was 80 to 80 . Clinically, the patient reported no pain, and the elbow was stable. Radiography confirmed the consolidation of the fibular graft to the humerus (Fig. 6, A and B). At 20 months postsurgery, the patient was subjectively highly satisfied and clinically retained movement and stability of the elbow.
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Figure 5
Range of motion for elbow (A) flexion and (B) extension at 12 months postsurgery.
Figure 6
(A) Lateral and (B) anteroposterior radiographs at 12 months postsurgery.
Discussion Infection is one of the worst complications of open joint fractures. Unfavorable progress due to concomitant factors, such as the virulence of the microorganism involved, the presence of soft-tissue damage, and devascularization and necrosis of bone, may lead to joint destruction with bone loss presenting a challenge for treatment. Associated factors, including patient age and the functionality of the joint for daily domestic and professional life, should be taken into account when deciding on the treatment strategy. Here, an infected fracture requiring various operations, leading eventually to floating elbow in the nondominant arm of a 39-year-old man, prompted consideration of a range of treatment options, examined below. Elbow arthrodesis9 in various positions is recommended in the literature for infections and defects that cannot be managed by prosthesis implantation or other methods. Another option is joint reconstruction using a fresh frozen allograft. Dean et al4 reported in 1997 a group of 23 patients who underwent elbow allograft reconstruction, with varying results and a high complication rate. Use of a conventional prosthesis is another option, although there is a danger of instability and possible loosening: simple, rigid types of prostheses are known to lead to premature loosening.8,13 Patient age is a key factor: Celli and Morrey3 report revision rates of 22% within the first
91 months for patients receiving an elbow replacement before the age of 40. Here, massive bone loss suggested the possibility of a custom-made prosthesis5, although such prostheses, due to being constrained, are associated with higher rates of loosening. A further option was an allograftprosthetic composite.1,10 Morrey et al,12 in a study of 25 patients undergoing revision total arthroplasty using an allograft prosthetic composite, reported a revision rate of 38% and a high rate of complications, leading to 33% failure in case of surgery for infection. The last option was elbow interposition arthroplasty, reportedly a viable approach for elbow arthritis in patients too young to be candidates for a prosthetic joint replacement.6,11 This technique preserves the basic anatomy of the elbow, but where there is irreparable damage to the cartilage, interposition of soft tissuedgenerally tendinousdfrom the joint surface provides an acceptable range of movement and causes little pain, achieving good results in the medium-term to long-term. In our patient, however, bone loss was so great that reconstruction using a vascularized bone graft with the functionality of an interposition arthroplasty was deemed to be the best strategy. Vascularized bone transfers have been successfully used on a number of occasions. Hattori et al7 reported the use of vascularized iliac bone graft for reconstruction of massive bone defect of the distal humerus, with good results. More recently, Cavadas et al2 described use of vascularized iliac crest or fibular osteocutaneous grafts to reconstruct massive
Massive bone loss in elbow bone loss in 5 patients aged younger than 40 years. Mean follow-up was 22 months, mean range of motion was 86 , patients reported no significant pain, and lateral stability was acceptable. External fixation was maintained for 4 weeks, and secondary reconstruction of lateral ligaments was performed 6 to 8 weeks later using an autologous tendon graft. Here, the treatment of choice for reconstruction of bone defect was interposition arthroplasty using a vascularized fibular transfer. The choice was governed by 3 major considerations: (1) floating elbow caused by a complex open fracture that subsequently became infected by aggressive microorganisms, requiring several operations; (2) significant bone loss, involving approximately 6 cm of the distal third of the humerus; and (3) patient age. Use of a vascularized fibular transfer with periosteum and some muscle tissue interpositioned in the bone enabled the anatomy of the distal portion of the humerus to be reconstructed and was functionally comparable to the interposition of soft tissue in classical interpositional arthroplasty. Use of a vascular graft avoided bone resorption, and the mediumterm and long-term outcome was promising. Dynamic compression plates and minimal osteosynthesis were used in view of the risk of reactivation of infection. External ligaments were released and then reattached to the vascularized graft. An external distraction fixator was left in place for 3 months to aid consolidation of the fibular graft osteoclasis and ensure elbow stability, with no need for secondary lateral-ligament surgery. Clinical results and elbow stability were good, as was medium-term patient satisfaction. Although no clinical or radiographic deterioration was apparent after 20 months of follow-up, a longer period is required to better define the long-term fate of this autologous reconstruction. However, should this technique fail in the future, other viable options remain, including replacement arthroplasty or arthrodesis.
Conclusions Infection is a major potential complication of open joint fracture. Unfavorable progress may lead to extensive bone loss, seriously hampering treatment. In this case study, a 39-year-old man who had undergone surgery on several occasions for an infected open fracture presented with floating elbow accompanied by the loss of approximately 6 cm of bone from the distal humerus. Possible treatment options, given the extent of joint involvement, were arthrodesis, allograft-prosthetic composite, or interposition arthroplasty with vascularized bone. Interposition arthroplasty using a vascularized fibular bone graft was the treatment chosen. A good functional outcome was apparent after a limited
e147 20-month follow-up, and the patient was highly satisfied with the result.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Amirfeyz R, Stanley D. Allograft-prosthesis composite reconstruction for the management of failed elbow replacement with massive structural bone loss: a medium-term follow-up. J Bone Joint Surg Br 2011; 93:1382-8. http://dx.doi.org/10.1302/0301-620X.93B10.26729 2. Cavadas PC, Landi L, Thione A, Iba~nez J, Nthumba P, Roger I. Reconstruction of massive bone losses of the elbow with vascularized bone transfers. Plast Reconstr Surg 2010;126:964-72. http://dx.doi. org/10.1097/PRS.0b013e3181e6b0b9 3. Celli A, Morrey BF. Total elbow arthroplasty in patients forty years of age or less. J Bone Joint Surg Am 2009;91:1414-8. http://dx.doi.org/ 10.2106/JBJS.G.00329 4. Dean GS, Holliger EH, Urbaniak JR. Elbow allograft for reconstruction of the elbow with massive bone loss. Long term results. Clin Orthop Relat Res 1997;341:12-22. 5. Franke A, Bieler D, Hentsch S, Johann M, Kollig E. Reconstruction of an elbow joint after blast injury by arthroplasty with a custom-made modified total elbow prosthesis: a case report. J Shoulder Elbow Surg 2014;23:e81-7. http://dx.doi.org/10.1016/j.jse.2014.01.013 6. Froimson AI, Silva JE, Richey DG. Cutis arthroplasty of the elbow joint. J Bone Joint Surg Am 1976;58:863-5. 7. Hattori Y, Doi K, Pagsaligan JM, Takka S, Ikeda K. Vascularized iliac bone graft for reconstruction of massive bone defect of the distal humerus. J Reconstr Microsurg 2005;21:287-91. http://dx.doi.org/10. 1055/s-2005-871768 8. Kim JM, Mudgal CS, Konopka JK, Jupiter JB. Complications of total elbow arthroplasty. J Am Acad Orthop Surg 2011;19:328-39. 9. Koller H, Kolb K, Assuncao A, Kolb W, Holz U. The fate of elbow arthrodesis: indications, techniques and outcome in fourteen patients. J Shoulder Elbow Surg 2008;17:293-306. http://dx.doi.org/10.1016/j. jse.2007.06.008 10. Mansat P, Adams RA, Morrey BF. Allograft-prothesis composite for revision of catastrophic failure of total elbow arthroplasty. J Bone Joint Surg Am 2004;86:724-35. 11. Morrey BF. Distraction arthroplasty: clinical applications. Clin Orthop Relat Res 1993;293:46-54. 12. Morrey ME, Sanchez-Sotelo J, Abdel MP, Morrey BF. AllograftProsthetic composite reconstruction for massive bone loss including catastrophic failure in total elbow arthroplasty. J Bone Joint Surg Am 2013;95:1117-24. http://dx.doi.org/10.2106/JBJS.L.00747 13. Voloshin I, Schippert DW, Kakar S, Kaye EK, Morrey BF. Complications of total elbow replacement: a systematic review. J Shoulder Elbow Surg 2011;20:158-68. http://dx.doi.org/10.1016/j.jse. 2010.08.026
