Custom distal humeral replacement with locked flange in revision total elbow arthroplasty

Revision total elbow arthroplasty (TEA) is increasing as the number of primary TEA increases. In a revision setting, surgeons often face the challenge of distal humeral bone loss. Techniques described include large segment allografts, allograft prosthetic composites, and megaprosthesis. Within the literature, there is limited evidence on the use of megaprosthesis in a revision TEA setting for nontumor indications. We present our institutions' experience of managing significant distal humeral bone loss in this context using a novel custom uncemented distal humeral replacement with a locked flange. Patients were identified using a tertiary center's local joint registry alongside electronic patient records. Variables collected included patient demographics, indication, number of previous surgeries, range of movement, complications, Oxford Elbow Score, pain score, EuroQol 5 Dimensions, and Single Assessment Numerical Evaluation scores. The cohort comprised 11 patients with custom distal humeral replacements. The mean age was 66 years (range, 47-79 years). The mean follow-up was 32 months (range, 6-93 months). The mean number of prior procedures was 6. Indications for the revision TEA were 4 for aseptic loosening, 5 for infection, 1 for failed fracture fixation, and 1 for periprosthetic fracture. The cohort demonstrated improvements in their range of movement as well as mean Oxford Elbow Score, Single Assessment Numerical Evaluation, EuroQol 5 Dimensions, and pain score. Two patients have since required further surgery, one due to implant dissociation and one due to recurrent deep infection. Bone loss in the distal humerus can provide a complex challenge in the revision setting. The use of custom megaprosthesis has evolved due to challenges associated with alternative strategies. However, there are limited data in the literature regarding outcomes in a nontumor setting. We report good early to midterm clinical and radiographic outcomes of a custom uncemented distal humeral replacement with a locked flange design and a lower complication rate compared with alternative surgical techniques reported in the literature.