Strut allograft augmentation restores bone stock in revision elbow arthroplasty, but is not universally successful in preventing a second revision

Strut allograft reconstruction represents an appealing option to address bone deficiency in revision total elbow arthroplasty (TEA), offering immediate structural support and potential for graft incorporation to restore bone stock. However, evidence supporting its efficacy is limited to small case series studies. This study aimed to assess strut allograft incorporation, complication, and re-revision rates in a large series of elbows that underwent revision TEA with strut allograft augmentation. Adult patients who underwent revision TEA with strut allograft augmentation between 1990 and 2024, with >2-year follow-up, were identified using our Institutional Total Joint Registry database. Those who had previously undergone TEA with strut augmentation and revisions performed using allograft prosthetic composites or custom-made implants were excluded. A total of 178 elbows (mean age 61 ± 12 years, 73% female) were included. The most common indications for revision TEA were aseptic loosening (55%), periprosthetic fracture (24%), and mechanical failure (10%). Sixty percent had undergone one prior TEA procedure, with the remaining having undergone 2 or more. Cortical strut allografts were most frequently used for humeral-sided reconstruction (48%), followed by ulnar-sided (38%) and both sides (13%). Medical records and radiographs were reviewed to confirm study eligibility and record demographic information, surgical indications, postoperative outcomes, and graft incorporation. Survivorship analyses were performed to determine cumulative incidences of re-revision TEA with death as a competing risk. The mean follow-up time was 9 ± 6 years. Strut allograft augmentation allowed satisfactory implantation of off-the-shelf implants in all elbows. However, 55 (31%) eventually underwent re-revision at a mean of 6 ± 5 years, postoperatively. Among the 121 elbows with available follow-up radiographs, 113 (93%) demonstrated graft incorporation. Cumulative incidences of re-revision TEA at 1, 2, 5, and 10 years were 5% (95% confidence interval [CI] 2-9), 7% (95% CI 4-12), 18% (95% CI 13-24), and 24% (95% CI 19-32), respectively. Aseptic loosening (44%), infection (29%), and periprosthetic fracture (18%) were the most common indications for re-revision. Of the periprosthetic fractures, the majority occurred in cases where the strut and implant ended at the same level (46%) or when the strut had failed to incorporate (31%). Deficient bone stock can be effectively managed with strut allograft augmentation in revision TEA with high rates of graft incorporation. Risk of subsequent periprosthetic fracture may be related to the strut and implant ending at the same level. Despite early success within the first 2 years, survivorship free of revision declines to 75% at 10 years.