Mid-term outcomes of surgical management of complex, isolated radial head fractures: a multicentre collaboration

Analysis of Surgical Stabilization Results of Radial Head Fractures

Background/Objectives: According to the modified Mason classification, radial head fractures can be treated with open reduction and internal fixation (ORIF), radial head arthroplasty, or resection. This study by the Department of Traumatology and Orthopedics of the Military Institute of Medicine aimed to compare the clinical and radiological outcomes of fractures treated with ORIF. Methods: This retrospective study analyzed 55 patients with radial head fractures treated between April 2020 and February 2023. Fractures were classified using Mason system as 15 type II, 26 type III, and 14 type IV. Clinical outcomes were evaluated using the VAS for pain, Broberg-Morrey scale, and the DASH questionnaire, alongside assessments of range of motion, grip strength, and elbow stability. Follow-up radiographs examined bone union, bone fragments displacement, degenerative changes and periarticular ossification. Results: The mean follow-up period was 21.0 ± 10.2 months. There were no statistically significant differences in VAS scale results for Mason types II, III, and IV fractures (4.0 vs. 6.0 vs. 5.0, respectively; p = 0.825), the Broberg-Morrey scale (82.0 ± 15.2 vs. 80.9 ± 15.5 vs. 84.2 ± 15.1, respectively; p = 0.845), or the DASH questionnaire (10.0 vs. 11.7 vs. 17.5, respectively; p = 0.937). Mean extension deficit and supination angles were at the limit of statistical significance (p = 0.076 and p = 0.051). No cases of lateral instability were observed, whereas medial instability was seen in only one case. Bone union was observed in 97.5% of cases, with elbow joint osteoarthritis and periarticular ossification in 15.0% and 45.0% of cases, respectively. Conclusions: Mason type II, III and IV radial head fractures treated with open reduction and internal fixation showed good functional and radiological outcomes with rare complications, including degenerative changes, periarticular ossifications and nonunion.

Minimum 10-year follow-up after open reduction and internal fixation of radial head fractures Mason type II and III

BACKGROUND

The treatment of complex radial head fractures remains controversial with open reduction and internal fixation (ORIF), radial head arthroplasty, and radial head excision being the most common treatment options. While ORIF is the preferred treatment strategy for Mason type II fractures, the optimal treatment of Mason type III fractures is debated. The purpose of this study was to report minimum 10-year outcomes after ORIF of Mason type II and type III radial head fractures. We hypothesized that both Mason Type II and Type III fracture patients would demonstrate satisfactory clinical outcomes at minimum 10-year follow-up.

METHODS

All patients with Mason type II or III radial head fractures who were treated with ORIF by a single surgeon between 2005 and 2010 were included. Fractures with significant bone defects were treated with bone grafts and elbow ligament injuries were treated with either primary ligament repair or reconstruction. Patient reported outcome questionnaires were administered at the time of last clinical follow-up and at a minimum of 10 years postoperatively.

RESULTS

Twenty-four patients, including 13 male and 11 female patients with an average age of 39 (range 19-60) at the time of surgery met inclusion criteria. Thirteen patients suffered from Mason type II and 11 patients from Mason type III fractures. At initial follow-up, 21 out of 24 fractures (88%) demonstrated radiographic union. Three nonunions, 2 of which were Mason type III fractures, were treated with revision ORIF and iliac crest bone grafting. 11 patients developed postoperative elbow stiffness and required capsular release surgery. At last clinical follow-up, average flexion was 139°, average extension was 4°, average supination was 77°, and average pronation was 81°. The median Disabilities of the Arm, Shoulder and Hand score was 7 (ranging from 0 to 32). Minimum 10-year follow-up (mean: 14.6 years) was collected on 18 of 24 (75%) of the patients. At a minimum of 10 years postoperatively, the median QuickDASH score was 4.5 (range: 0 to 25) and the median SANE score was 96.5 (range: 75-100). Median satisfaction with the surgical outcome was 10 of 10 (range: 3-10).

CONCLUSION

ORIF of Mason type II and III radial head fractures results in high union rates with good functional outcomes at a mean of 14.6 years postoperatively. The study results suggest that ORIF of Mason type II and III radial head fractures leads to long-term positive functional outcomes.

Type of fixation is not associated with range of motion after operative treatment of proximal radius fractures- a systematic review of 519 patients

Background

The aims of this study are 1) to assess whether open reduction internal fixation (ORIF) techniques for fractures of the proximal radius are associated with the range of motion (ROM), 2) to determine the incidence of hardware-related complications and removal following plate and screw fixation of the proximal radius, and 3) to evaluate whether the safe-zone definition is described in the literature and its relation to the ROM.

Methods

A literature search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting ROM in patients undergoing ORIF for radial head or neck fractures were included. Two treatment groups were defined based on ORIF technique: screws only or plates with and without additional screw placement.

Results

A total of 13 articles were included with 519 patients, of which 271 belonged to the screw group and 248 to the plate group. At final follow-up, the screw group reported a mean supination of 79 (95% CI: 74-83), pronation of 76 (95% CI: 69-84), flexion of 131 (95% CI: 124-138), and loss of extension of 4 (95% CI: 1-7). The plate group reported a mean supination of 72 (95% CI: 65-80), pronation of 697 (95% CI: 60-75), flexion of 126 (95% CI: 118-133), and loss of extension of 7 (95% CI: 1-14).

Conclusion

Predominantly retrospective studies show that the ROM seems similar for screw and plate osteosynthesis of proximal radius fractures. Complication rates are similar as well. The safe-zone definition is rarely reported.

Association of Radial Head Fracture Treatment With Long-Term Function

BACKGROUND

Radial head fractures are often associated with poor outcomes. Both open reduction and internal fixation (ORIF) and radial head arthroplasty (RHA) might be considered in operative cases. This study aimed to compare long-term patient-reported functional outcomes among patients with operatively treated radial head fractures.

METHODS

A cross sectional study conducted at a Level I trauma center was used to identify patients with a radial head fracture who underwent ORIF or RHA between 2006 and 2018, and agreed to complete a survey in 2020. The primary outcome measure was the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score.

RESULTS

Seventy-six patients participated in the study. No significant differences in outcomes were observed between groups. QuickDASH scores were similar for both groups (ORIF: mean = 15.7, SD = 18.4; RHA: mean = 22.8, SD = 18.6; mean difference = 0.2 [-9.0 to 9.3], P = .97). Nineteen (37%) ORIF patients and 12 (48%) RHA patients reported a need for pain medication (adjusted odds ratio [OR] = 0.8 [0.3-2.4], P = .70). Thirteen (25%) ORIF patients and 6 (24%) RHA patients required additional surgery (adjusted OR = 1.7 [0.5-6.2], P = .39). A subgroup analysis of multi-fragmentary fractures revealed similar findings.

CONCLUSION

Patient-reported outcomes, which included a subgroup analysis of multi-fragmentary fractures, were similar between ORIF and RHA groups at an average of 7.5 years from surgery. Reconstructing the radial head might not result in worse outcomes than RHA when both options are employed according to the best judgment of the operating surgeon.

Comparative Study Between the Mini-Open (≤2.5 Cm) Approach and Conventional Open Lateral Approach in the Surgical Treatment of Radial Head Fractures

PURPOSE

The conventional lateral approach is widely used to treat radial head fractures with screws. However, the traditional incision may have shortcomings, including excessive exposure and significant scarring. We propose an innovative method - a mini-open lateral approach of less than 2.5 cm for surgical treatment of radial head fractures with screws.

METHODS

From Jan 2017 to Dec 2020, 34 patients diagnosed with closed radial head fracture were treated with open reduction and internal fixation (ORIF) in this study. The novel group (mini-open group) included 15 patients, and the other 19 patients were in the traditional group. The time of operation and the blood loss during operation were recorded. Postoperative clinical outcomes and radiographic results were recorded and compared between the two groups. The range of motion (ROM) in the elbow, the Visual Analogue Scale (VAS), the Mayo Elbow Performance Score (MEPS), Rating Scale of the American Shoulder and Elbow Surgeons (ASES), and the Shortened Disabilities of the Arm, Shoulder and Hand Questionnaire (Q-DASH) score and complications, such as wound infection, vascular and nerve damage, and fragment redisplacement were observed in the two groups.

RESULTS

In the comparison between the two groups, there was no significant difference in age, sex, cause of radial head fracture, or other basic information. The operation time, intraoperative blood loss, and VAS score at 3 days postoperation were significantly reduced in the novel group (p < 0.05). The follow-up results showed that there was no significant difference in MEPS, ASES, or Q-DASH scores between the two groups.

CONCLUSION

The mini-open approach reduced intraoperative blood loss, shortened operation time, relieved patient pain, and achieved a satisfactory postoperative clinical result, which demonstrates that the novel approach is a safe and effective option for treating radial head fractures.

Excision Versus Replacement in Unrepairable Comminuted Fractures of the Radial Head: A Systematic Review of Outcomes and Complications

BACKGROUND

The radial head fractures comprise approximately 4% of all fractures around the elbow. The outcomes of open reduction and internal fixation are poor in fractures with more than three fragments, and the excision of radial head is considered a viable surgical treatment option. However, it is associated with its own set of complications. The radial head prosthetic replacement has emerged as an alternative in management of these fractures with constraints of cost and related complications. Hence, the treatment for the unrepairable comminuted radial head fractures still remains controversial.

AIMS AND OBJECTIVES

This systematic review and meta-analysis was conducted to compare the post-operative outcomes of the radial head excision versus prosthetic replacement in comminuted Mason type-III fractures of radial head.

METHODOLOGY

Three databases of Medline (PubMed), Scopus, and Embase were searched for comparative studies on the study question and relevant studies which mentioned at least one of the outcomes of interest (functional outcome scores and number of complications) were included.

RESULTS

Six studies were part of this review with 82 excisions and 99 prosthetic replacements. There was no significant difference between the two groups in terms of number of complications (OR 0.65; 0.08-5.07); and measures of functional outcomes; Mayo elbow performance score or MEPS (mean difference - 6.56; - 23.45 to 10.33). The incidence of elbow osteoarthritis, heterotrophic ossification, stiffness, and instability were similar in both groups. The flexion extension arc in degrees was better in excision group (mean difference 9.93; 1.31-18.55; p = .02).

CONCLUSION

Excision is a reasonable surgical option for isolated comminuted radial head fractures with similar results of function and associated rates of complications as prosthetic replacements. The arc of motion is also better with excisions. There have been reports of more osteoarthritis with excision and arthroplasty has been advised in younger patients; however, we had no quantitative proof of that in this review.

A hybrid technique combining intramedullary pinning with extramedullary plate fixation in unstable and comminuted radial head fractures following on-table reconstruction

Background

Management of comminuted radial fractures remains controversial. Currently, the emergence of on-table reconstruction technique has made fixation in comminuted radial head fractures more viable. However, the present study reported an intro-operative unstable displacement from the reconstructed radial head to the neck during plate fixation, characterized by a poor radiocapitellar contact and incongruity between the radial head and neck. A hybrid technique combining with intramedullary pining was performed in our study to restore the normal alignment and maintain the stability of fixation. Therefore, the purpose of this article aimed to prove the feasibility of unstable comminuted radial head fractures treated with the extramedullary plate and intramedullary pinning fixation using titanium elastic nails.

Methods

The clinical, functional and radiographic outcomes of the groups were compared during follow-up. The radiographic examination was conducted to evaluate the status of bone union, heterotopic ossification and post-traumatic arthritis. The functional assessment was performed to evaluate clinical effects, which included measurements of range of motion (ROM) in the elbow, Visual Analog Scale (VAS) score, Elbow Self-Assessment score (ESAS), Mayo Elbow Performance score (MEPS), and Disabilities of the Arm, Shoulder, and Hand (DASH)Outcome Measure score.

Results

Thirteen patients with unstable fractures were participated with an average follow-up of (38.6 ± 4.5) months for the experimental group and (32.0 ± 6.3) months for the control group, respectively. The functional outcomes in the experimental group, including MEPS and DASH, were significantly superior to the control group. However, no significant difference was observed in the elbow ROM and VAS score between two groups. In the last follow-up, one patient with post-traumatic arthritis rated as grades 1 and two with heterotopic ossifications were observed in the experimental group. In the control group, degenerative changes were observed in three cases (grade 1 in two cases and grade 2 in one case) and heterotopic ossifications rated as grade I were found in two patients.

Conclusion

Collectively, intramedullary pinning with extramedullary plate fixation is feasible in unstable comminuted radial head fractures, which can be considered as a remedial surgery for on-table reconstruction technique.