Management of comminuted radial head fractures with replacement arthroplasty

Clinical and functional outcomes of plate and screw osteosynthesis in mason type III and IV radial head fractures in the absence of a radial head prosthesis

INTRODUCTION

Radial head and neck fractures represent a significant portion of elbow fractures in adults, particularly affecting younger patients due to falls onto outstretched hands. Surgical treatment is often necessary for displaced and comminuted fractures, especially those with associated ligamentous injuries. This study evaluates the long-term clinical, functional, and radiological outcomes of patients with Mason type III and IV radial head fractures managed through open reduction and internal fixation using plate and screw osteosynthesis, due to the unavailability of radial head prostheses.

MATERIAL AND METHOD

We retrospectively analyzed 28 patients with Mason type III or IV radial head fractures treated with open reduction and internal fixation (ORIF) between 2020 and 2024. Clinical assessments included the visual analog scale (VAS) for pain, Mayo Elbow Performance (MEP) Score, and Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) score, as well as measurements of elbow flexion, extension, supination, and pronation. Radiographic evaluations assessed fracture union, loss of reduction, implant breakage or loosening, avascular necrosis, radiographic arthritis, and heterotopic ossification.

RESULTS

At a mean follow-up of 29.1 ± 20.1 months in 28 patients (16 M/12F; mean age 48.5 ± 12.6 years), mean elbow flexion was 120.4 ± 14.7, extension loss 10 ± 5.9, supination 68.9 ± 8.8°, and pronation 62.8 ± 7.1°, with mean VAS 2.3 ± 1.1, MEP Score 83.0 ± 8.9, and Quick-DASH 12.8 ± 7.6. Complete fracture union was achieved in 25 cases, partial union in 2, and asymptomatic nonunion in 1. Complications occurred in three patients (10%), including implant loosening, loss of reduction, heterotopic ossification, and avascular necrosis; two patients showed post-traumatic degenerative changes. One patient required K-wire removal due to migration and another underwent revision fixation with iliac crest bone graft for screw loosening/nonunion. No cases needed open arthrolysis or secondary radial head resection.

CONCLUSION

While osteosynthesis is effective in managing Mason type III and IV radial head fractures, having a radial head prosthesis available in the operating room can provide flexibility, especially in comminuted fractures, and potentially reduce the need for revision surgeries. These findings underscore the importance of adaptable surgical planning to improve outcomes in complex radial head fractures.

Long-term outcomes of a cemented bipolar radial head prosthesis: a large retrospective study

BACKGROUND

In acute radial head fractures (RHFs), a radial head prosthesis can be considered if open reduction and internal fixation are not technically feasible. This study provides the largest long-term clinical and radiologic follow-up study of cemented bipolar Judet prostheses implanted to manage acute RHFs, either isolated and associated with other elbow fractures. We compare their functional and radiographic outcomes to test the hypothesis that the bipolar design can achieve similar results in both groups.

METHODS

We reviewed data of 63 consecutive patients implanted with a bipolar prosthesis (the articulation between the stem and the cup is semiconstrained and gives the radial cup a double range of movement) to treat unreconstructable RHFs with/without other fractures. Fifty-two patients had more than 10-year follow-up. Assessments included range of motion and stability using the Mayo Elbow Performance Score and the QuickDash questionnaire score, pain with a visual analog scale, and overall satisfaction with an interview. X-rays were examined to check the correct seating of the implant and periprosthetic loosening, prosthetic disassembly, heterotopic ossification, and capitellum and ulnohumeral degenerative changes.

RESULTS

At a mean follow-up of 150 months, 90% of patients were satisfied, with a mean Mayo Elbow Performance Score of 89 (range, 70-100) and a mean QuickDash score of 6.8 (range, 0-18.2). The mean arc of motion was 113° (range, 70°-140°) in flexion-extension and 149° (range, 100°-160°) in pronation-supination. Nineteen patients (30%) patients required reoperation in the first 3 years.

CONCLUSIONS

The bipolar Judet prosthesis is a viable implant for acute irreducible RHFs. Clinical and radiologic outcomes and complications leading to reoperation were not significantly different between isolated radial head fractures and associated radial head fractures patients.

Advances in the pathology and treatment of osteoarthritis

BACKGROUND

Osteoarthritis (OA), a widespread degenerative joint disease, predominantly affects individuals from middle age onwards, exhibiting non-inflammatory characteristics. OA leads to the gradual deterioration of articular cartilage and subchondral bone, causing pain and reduced mobility. The risk of OA increases with age, making it a critical health concern for seniors. Despite significant research efforts and various therapeutic approaches, the precise causes of OA remain unclear.

AIM OF REVIEW

This paper provides a thorough examination of OA characteristics, pathogenic mechanisms at various levels, and personalized treatment strategies for different OA stages. The review aims to enhance understanding of disease mechanisms and establish a theoretical framework for developing more effective therapeutic interventions.

KEY SCIENTIFIC CONCEPTS OF REVIEW

This review systematically examines OA through multiple perspectives, integrating current knowledge of clinical presentation, pathological mechanisms, and associated signaling pathways. It assesses diagnostic methods and reviews both pharmacological and surgical treatments for OA, as well as emerging tissue engineering approaches to manage the disease. While therapeutic strategies such as exercise, anti-inflammatory drugs, and surgical interventions are employed to manage symptoms and modify joint structure, none have been able to effectively halt OA's advancement or achieve long-lasting symptom relief. Tissue engineering strategies, such as cell-seeded scaffolds, supportive matrices, and growth factor delivery, have emerged as promising approaches for cartilage repair and OA treatment. To combat the debilitating effects of OA, it is crucial to investigate the molecular basis of its pathogenesis and seek out innovative therapeutic targets for more potent preventive and treatment strategies.

Long-terms outcomes of radial head arthroplasty using a bipolar prosthesis

BACKGROUND

In acute treatment of radial head fractures, a radial head prosthesis can be considered if open reduction and internal fixation are not technically feasible.

METHODS

We reviewed the data of 27 consecutive bipolar Judet radial head prostheses implanted in patients with unreconstructable radial head fractures and no other concomitant fractures (coronoid or olecranon factures). The lesions of the lateral collateral ligament were rated according to the McKee classification. Twenty-three patients with more than ten-year follow-up participated in this retrospective study All patients underwent assessments for pain, range of motion and stability using the Mayo Elbow Performance Score, the QuickDash questionnaire and a Visual Analogue Scale for pain. Radiography assessment was performed to determine the correct setting of the implant, presence of periprosthetic loosening, prosthetic disassembly, heterotopic ossification, capitellum and ulnohumeral degenerative changes.

RESULTS

Mean follow-up was 149 months (± 12.2). Mean range of motion in flexion-extension was 111° (± 10.55), mean extension was 18° (± 14.32) and mean flexion was 130° (± 11.4). Mean arc of motion in supination-pronation was 150° (± 12.26). The mean Mayo Elbow Performance Score was 88, the mean QuickDash score was 7.3; 86% of the patients were satisfied. Seven patients (26%) required secondary surgery. The most frequent complication was heterotopic ossification, which had negative consequences on the functional result.

CONCLUSIONS

Bipolar radial head prostheses are an option for acute treatment of isolated unreconstructable radial head fractures. During follow-up, three patients required implant revision and removal; the capitellum surface presented severe degenerative changes and the prosthesis was not replaced. Another complication was the risk of implant dislocation, in relation to implant design, incorrect positioning of the radial head stem or else to inadequate reconstruction of the lateral collateral ligament. Further work is needed to establish the long-term follow-up results of Judet implants in complex elbow fractures.

Treatment of comminuted radial head fractures with personalized radial head prosthesis produced with 3-dimensional printing technology

BACKGROUND

The radial head is the forearm's pivot point for supination-pronation. Although radial head resection can be performed in comminuted radial head fractures, radial head prosthesis has gained popularity in order to prevent possible complications such as progressive valgus instability in the elbow and secondary ulnocarpal impaction that may develop due to proximal displacement of the radius. As for radial head prostheses, standard prosthetic designs do not provide the same results in everyone, and the alignment of the radial head and radial neck angle cannot be fully achieved. We believe that the radial head must be reconstructed with a complete anatomical implant. We designed and applied personalized prostheses to our patients, and in this study, we wished to share the 2-year results of these patients.

METHODS

In this study, 23 patients who had comminuted radial head fractures had personalized radial head prostheses inserted. Preoperative variables such as type of injury, age, side, additional ligament injury, operation time, number of radial head parts, neck angle of individual prosthesis, stem length, and stem diameter were noted. The mean operating time was 26 ± 9 minutes. One month postoperatively, after physical therapy, elbow range of motion, loss of strength compared to the opposite joint, Mayo elbow scores, QuickDASH scores, and patient satisfaction were evaluated. Patients were evaluated 2 years postoperatively.

RESULTS

QuickDASH and Mayo elbow scores were satisfactorily good (mean QuickDASH score: 9.091, mean Mayo score: 91.08). According to the results of the patient satisfaction questionnaire, 16 of the 23 patients reported excellent satisfaction, 5 patients good satisfaction, and 2 patients moderate satisfaction. None of the patients reported poor results.

DISCUSSION

Since personalized radial head prosthesis consists of a single monoblock, its surgical application consists of a single step and has a short operating time. As the applications in the literature increase and more studies are conducted, this subject will be better understood. Our study demonstrated that these patients, whose anatomies were individually replicated, achieved good range of motion and patient satisfaction. In fact, none of the patients reported negative results. In comminuted radial head fractures, surgical implantation of personalized radial head prosthesis is a treatment modality with easy application, short operating time, and good functional results.

The Influence of Medial Comminution in the Treatment Choice of Radial Head Fracture

Introduction:

The aim of our retrospective study was to investigate the role of the medial side involvement in the treatment choice of radial head fractures.

Materials and Methods:

We searched the databases of our institutions for the surgical procedures diagnosed as "fracture of the radial head" and for the procedures related to "prosthesis of the radial head" and "osteosynthesis of the radial head" in the period from May 2014 to October 2017. The fractures were first classified according to the Mason classification . We then allocated the patients into three study groups according to the site of the fracture, either the medial or lateral side of the radial head : Group A, with an isolated lateral fracture of the radius head; Group B1, with a medial fracture of the radius head with two medial fragments; and Group B2, with a medial fracture of the radius head with multiple medial fragments. We performed a multivariate analysis to identify statistically significant correlation between the pre-operative classifications of Mason and our study, the type of surgical procedure, and the clinical outcome.

Results:

Mayo Elbow Performance (MEP) scores determined at the final follow-up of the study (mean 16.6 months, range 12-26 months) was excellent in 17 patients (4 in Group A, 6 in Group B1 and 7 in Group B2), and good in 12 patients (3 in Group A, 7 in Group B1, and 2 in Group B2). One patient showed a poor result in MEP score probably because of an infection and implant removal.

Conclusion:

Regarding medial fractures of the radial head, our study showed satisfactory results with a radial head prosthesis for comminuted or multifragmentary radial head fractures. For surgeons with advanced elbow fracture expertise, osteosynthesis could be attempted in a fracture pattern that involved only two medial fragments.

Matching precision of the reverse contralateral radial head in generating of the individualized prosthesis from the surface registration in tuberosity-neck and in tuberosity-diaphysis

PURPOSE

Following the radial head replacement, the surface mismatches between the implants and the morphological characteristics of the original proximal radius decreased contact areas and increased contact forces which is potential for the long-term articulating cartilage wear. Several studies demonstrated that the individualized prosthesis, created from computed tomographic (CT) images of the contralateral side with the reverse engineering technology, may reduce the mismatch. The aim of this study is to demonstrate the matching precision of the reverse contralateral head between the surface registration in tuberosity-neck (TN) area and in tuberosity-diaphysis (TD) area.

MATERIALS AND METHODS

High-resolution CT scan of 11 pairs of the cadaveric arms was performed. Utilizing advanced image processing techniques, three-dimensional (3-D) models of each specimen was generated. The model of the left side was reversed and matched with the model of the right side in the same cadaver by registering in the area of radial neck along with tuberosity (TN) and in the area of radial tuberosity combined with 2 cm of proximal diaphysis (TD). The alteration of the head diameter, dish diameter, articular depth, head thickness, end-plane angle, offset, and head volume were evaluated and analyzed by paired t-test.

RESULTS

No statistically significant difference was found in all parameters from both TN and TD registrations ( p < 0.05).

CONCLUSION

The surface registration in either TN or TD area can generate the statistically symmetrical 3-D model with the original head. The registration in these areas may possibly be used in creating the individualized radial head prosthesis.

Complex radial head and neck fractures treated with modern locking plate fixation

BACKGROUND

Internal fixation of complex radial head and neck (CRHN) fractures is difficult, and postoperative complications are common. This study evaluated elbow function and patient clinical status after internal fixation of CRHN fractures with modern locking plates.

METHODS

We included 40 patients with 41 fractures (1 bilateral lesion). In 25 patients (61%), a concomitant injury was found. Patients were an average age of 46 years (range, 22-70 years). The mean follow-up time was 36 months (range, 2-70 months). Postoperative assessments included evaluation of range of motion, functional scores, and radiologic findings. We assessed fracture healing, surgical complications, revision surgery, and the need for metal removal.

RESULTS

Of the 34 fractures available for follow-up, 33 (97%) healed well. The mean extension deficit was 6° (range, 0°-30°). The average elbow flexion was 134° (range, 90°-160°), pronation was 70° (range, 30°-90°), and supination was 64° (range, 20°-90°). The Mayo Elbow Performance Score showed a mean of 90 points (range, 65-100 points). We observed no "poor" results. The mean Disability of Arm, Shoulder and Hand score was 16.5 (range, 2.5-58.3; n = 29). All patients continued activity without daily analgesics. There were 12 (34%) complications. In 11 (32%) patients, the plate was removed.

CONCLUSIONS

CRHN fractures fixed with modern locking plates and treated as an osseoligamentous lesion exhibited promising midterm results. The new fixation devices represent an improvement in the treatment of this difficult and common fracture while reducing the need for joint replacement or radial head resection. Diagnosis and treatment of concomitant injuries should be emphasized.

Replacement or repair of terrible triad of the elbow: A systematic review and meta-analysis

BACKGROUND

Surgical treatment for terrible triad injuries remains a challenging clinical problem, and controversy exists of whether it is better to repair or replace the radial head. The objective of this systematic review was to evaluate the clinical outcomes of repair and arthroplasty replacement of the radial head in patients with terrible triad injury.

METHODS

Medline, Cochrane Library, EMBASE, and Google Scholar were searched up to July 30, 2018 to identify the relevant studies, which included patients who had received treatments of the terrible triad of the elbow and also had reported with the quantitative outcomes. Outcomes of interest were functional outcomes.

RESULTS

Four studies with a total of 115 patients were included in the systematic review. Most patients were type II or III radial head fractures based on the Mason classification systems. Fifty-one patients received radial head repair surgery and 64 underwent replacement. Two studies had indicated that patients in the replacement group were significantly associated with better treatment outcome assessed by DASH (Disabilities of the Arm, Shoulder and Hand) and MEPS (Mayo Elbow Performance Score) scores. The meta-analysis indicated that patients with the arthroplasty replacement were associated with significantly better ROM outcomes in flexion, extension, pronation than those with radial head repaired. In addition, patients in the replacement group showed fewer post-surgery complications than those in the repair group.

CONCLUSIONS

Our review had indicated that patients with terrible triad injuries undergo arthroplasty replacement have better clinical outcomes and fewer post-surgery complications than those received the repair surgery. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow.

Results after radial head arthroplasty in unstable fractures

BACKGROUND

Whereas most radial head fractures are stable injuries, they sometimes occur as part of complex injury patterns with associated elbow instability. Radial head arthroplasty has been favored in patients with unreconstructable radial head fractures and unstable elbow injuries. The purpose of this study was to review radiographic outcomes, functional outcomes, and complications after radial head arthroplasty for radial head fracture in unstable elbow injuries.

METHODS

This study was a retrospective review of radial head fractures treated with radial head arthroplasty by a single surgeon during a 15-year period. Demographics of the patients, injury details, operative reports, radiographic and clinical outcomes, and any complications were recorded. Patients were divided into stable and unstable elbow injury groups.

RESULTS

A total of 68 patients were included. There were 50 unstable fractures that were compared with 18 stable fractures. Patients with unstable radial head fractures with associated elbow dislocation achieved mean flexion and mean forearm rotational arc of motion similar to that of patients with stable radial head fractures. However, supination loss was greater in the unstable group than in the stable fracture group, with a mean difference of 10°. Radiographic outcomes and complication rates did not differ between injury groups. There was no observed decrease in implant longevity in patients with unstable elbow injuries.

CONCLUSIONS

Radial head arthroplasty is an effective option for treatment of unstable elbow injuries, with recovery of functional elbow range of motion and no difference in complication rate or implant survivorship compared with those patients with stable injuries.

Radial Neck Dilatory Remodeling After Radial Head Arthroplasty With an Uncemented, Press Fit, Fully Chemically Etched Stem Design

OBJECTIVES

To compare the radiographic outcomes of 2 widely used side loading, press fit, RHA implants used to reconstruct complex elbow trauma.

DESIGN

Retrospective cohort study.

SETTING

Level-1 Academic trauma center.

PARTICIPANTS

Patients undergoing RHA.

INTERVENTION

Cohort 1 received Synthes Radial Head Prosthesis. Cohort 2 received Biomet ExploR Radial Head Replacement.

MAIN OUTCOME MEASUREMENTS

Radial neck dilatory remodeling.

RESULTS

Eighty-two subjects were included in final analysis, 63 from the Biomet Cohort, and 19 from Synthes cohort. Demographic and injury characteristics were similar among cohorts. Radial neck dilatory remodeling as well as periprosthetic radiographic lucency were seen significantly more frequently and to a significantly greater degree in the Synthes cohort. The average percentage of dilatory remodeling of the Synthes cohort was 34.9% and that of the Biomet cohort was 2.7%. There were no differences in rates of revision surgery.

CONCLUSIONS

Our study demonstrates significant radiographic differences between 2 frequently used RHA implants. Radial neck dilatory remodeling is a common, rapidly progressive, and dramatic finding frequently seen with the Synthes Radial Head Prosthesis.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Retrospective cohort study on radial head replacements comparing results between smooth and porous stem designs

BACKGROUND

When necessary, radial head integrity after a fracture can be re-created by the use of a radial head arthroplasty if the radial head is judged irreparable. The purpose of this study was to compare the clinical and radiographic outcomes of metal modular radial head replacements with a smooth vs. a porous stem.

METHODS

A retrospective cohort study of radial head replacements performed in the first 4 weeks after a trauma in an adult patient at our institution between 2000 and 2014 was completed. Patients were divided into 2 groups: a porous stem group (ExploR; Biomet Orthopedics, Warsaw, IN, USA) and a smooth stem group (EVOLVE; Wright Medical Group, Memphis, TN, USA). Primary outcomes were the Disabilities of the Arm, Shoulder, and Hand and Mayo Elbow Performance Index scores. Secondary outcomes were the visual analog scale score for pain, range of motion, grip strength, and radiographic evaluations.

RESULTS

Of the 80 eligible patients, 57 agreed to participate (porous stem group, 36; smooth stem group, 21). Demographic data were similar between the 2 groups. Average follow-up was 6.3 years. Average Disabilities of the Arm, Shoulder, and Hand and Mayo Elbow Performance Index scores were similar between the 2 groups. Porous implants were more prone to osteolysis (64.3% vs. 23.5%; P = .01) and were associated with a greater loss of elbow flexion (6° vs. 1°; P = .02). The porous stem group showed a tendency toward more overstuffing (24.0% vs. 5.9%; P = .21).

CONCLUSION

Our results reveal that outcomes between smooth and porous stem metal modular radial head implants are equivalent. However, the smooth stem implant may represent the preferred option as it is associated with a lower rate of complications.

Using an anatomically preshaped low-profile locking plate system leads to reliable results in comminuted radial head fractures

INTRODUCTION

For comminuted and displaced fractures of the radial head open reduction and internal fixation (ORIF) is recommended nowadays as the treatment of choice. Due to the development of locking plates the possibilities of ORIF in complex fracture types were extended. The purpose of this retrospective survey therefore was to review the preliminary subjective and objective results in patients treated by anatomically preshaped locked plating. A reliable fracture healing for these recently introduced plating devices was hypothesized.

MATERIALS AND METHODS

Subjective and objective criteria included patient's satisfaction, pain rating on a visual analogue scale (VAS) and active range of motion (ROM) compared to the contralateral armside. Functional scoring included the Morrey elbow performance score (MEPS), the QuickDASH and the elbow self-assessment score (ESAS). Furthermore, follow-up radiographs were reviewed.

RESULTS

Between 2011 and 2014 a total of 24 patients were managed with ORIF using anatomically preshaped low-profile locking plates. All patients had suffered from comminuted radial head fractures (type III-IV according to Mason classification). Twenty of 24 patients returned for follow-up examination after a mean of 30 months (range 18-53 months). Patients' satisfaction was rated as highly satisfied in 17 cases and satisfied in 3 cases. An unrestricted ROM for extension-flexion arc and pronation-supination arc was rated in 10 cases. Minor ROM deficiencies with a 5° limited extension compared to the contralateral side was evaluated in 6 cases. Only four patients were rated with and extension and supination deficiency of 10°, one of whom with an additional pronation deficiency of 10°. The calculated MEPS was Ø 98 ± 4 (range 85-100), and the QuickDASH was Ø 3 ± 6 (range 0-21). The ESAS was completed by 18 patients with a mean of Ø 96.54 ± 2.95 (range 94-100) indicating a non-restricted elbow function.

CONCLUSIONS

The treatment of comminuted radial head fractures using anatomically preshaped locking radial head plates represents a reliable and safe surgical approach, leading to good to excellent functional results. Being aware of the importance of the radial head for elbow stability, open reduction and internal fixation should be preferred prior to radial head resection or replacement in complex radial head fractures. Further trials with a higher number of patients are needed to confirm the advantages of preshaped radial head plates.

Treatment of Radial Head Fractures with a Modular Metallic Radial Head Replacement

Introduction

Radial head arthroplasty with a smooth-stemmed metallic modular implant is a reliable treatment option for patients with acute unreconstructible radial head fractures, and good clinical outcomes may be expected beyond 5 years of follow-up (Video 1).

Indications & Contraindications

Step 1 Preoperative Planning

Obtain a careful history and perform a physical examination along with appropriate imaging to facilitate appropriate treatment decisions.

Step 2 Operating Room Setup and Patient Positioning

Perform proper operating room setup and patient positioning, as they are required to gain access to all affected structures around the elbow in a safe and efficient manner.

Step 3 Approach

Make a midline posterior skin incision with development of a full-thickness lateral fasciocutaneous flap or use a direct lateral incision; the deep interval is determined on the basis of the integrity of the LCL.

Step 4 Radial Head Excision

Remove and preserve all fragments of the radial head for implant sizing.

Step 5 Implant Sizing

Implant a prosthesis that closely replicates the dimensions of the native radial head, which is the primary goal of the procedure.

Step 6 Stem Broaching

Sequentially broach the canal until good cortical contact is achieved and undersize the definitive stem by 1 mm to allow implant movement within the canal and appropriate articulation with the capitellum.

Step 7 Insertion of Trial Components and Final Radial Head Implant

With the selected trial in place, assess the radial head diameter, height, and articular congruency.

Step 8 Closure and Repair of the LCL

Ensure proper repair of the LCL as it is essential to maintaining or restoring elbow stability.

Step 9 Postoperative Protocol

Postoperative rehabilitation depends on the status of the collateral ligaments.

Results

In a review of the cases of 55 patients at a mean follow-up of 8 years after radial head arthroplasty with a smooth-stemmed modular metallic prosthesis, Marsh et al.⁹.

Pitfalls & Challenges

[Locking plate osteosynthesis of the radial head fractures : clinical and radiological results]

BACKGROUND

Therapy of radial head fractures is still controversially discussed. Especially comminuted fractures are at risk of complications such as radial head necrosis, nonunion and secondary loss of reduction after open reduction and internal fixation. The aim of this study was to evaluate clinical and radiographic results of ORIF (open reduction internal fixation) of radial head fractures using a new radial head-specific locking plate system.

PATIENTS AND METHODS

A total of 21 patients (13 men and 8 women) were treated with locking plate osteosynthesis of radial head fractures. Mean age was 50 years (range 29-67 years). According to the Mason classification, 15 were type III and 6 type IV. Mean time between trauma and surgery was 5.6 days (range 0-23 days). These patients were reexamined using the Mayo Elbow Performance Score and x-rays in two planes.

RESULTS

In all, 21 patients were reexamined with a mean follow-up of 12.1 months (range 5-23 months). The mean Mayo Elbow Performance Score was 87.1. Excellent results were obtained in 12 patients, good results in 6 patients, and fair results in 3 patients. Mean extension deficit was 12.1°, mean flexion 135.2°, mean pronation 70.9°, and mean supination 63.6°. All fractures healed uneventfully. There was no complete radial head necrosis but one partial. Four cases of heterotopic ossification were detected: Hastings classification I (n = 2), IIb (n = 1), IIIb (n = 1).

CONCLUSION

ORIF of radial head fractures using locking plates can lead to good and excellent results. Modern implants may allow for reconstruction of comminuted fractures avoiding arthroplasty in these young patients.

Factors associated with removal of a radial head prosthesis placed for acute trauma

PURPOSE

This study tests the hypothesis that there are no factors associated with removal or revision of a radial head prosthesis. A secondary analysis addressed the time to removal or revision.

METHODS

We reviewed the database of two large hospitals from 2000 to 2014 and identified 278 patients that had radial head replacement after an acute fracture or fracture dislocation of the elbow: 19 had removal and 3 had revision of the radial head implant within the study period. Explanatory variables including demographics, the type of injury, prosthesis type, surgeon, medical centre, and associated injuries were evaluated. Survival analysis using Kaplan-Meier curves evaluated time to removal/revision.

RESULTS

After adjustment for potential confounders using Cox regression multivariable analysis, hospital was the only factor independently associated with removal or revision (Hazard ratio=2.4, Confidence interval: 1.03-5.8, P value=0.043). The highest proportion of removal/revision was during the first year after implantation and decreased by half each year over the second to fourth years. The most common reason for removal of the prosthesis was to facilitate removal of heterotopic ossification (the majority with proximal radioulnar synostosis) rather than technical error or problems with the prostheses.

CONCLUSION

These findings suggest that the decision to remove a radial head prosthesis may depend more on surgeon or hospital preferences than on objective problems with the prosthesis. Until clarified by additional study, removal of a prosthesis should not be considered an objective outcome in research. In addition, patients offered removal of a radial head prosthesis, might get the opinion of more than one surgeon at more than one hospital before deciding whether or not to proceed.

LEVEL OF EVIDENCE

Level III Prognostic.

Outcomes Following Radial Head Arthroplasty

Most current series of radial head arthroplasty include small numbers of patients with short- to medium-term follow-up and significant heterogeneity in patients, treatments, and outcome measures. The purpose of this systematic review was to review outcomes for radial head arthroplasty based on injury chronicity, injury pattern, and type of implant used. The authors systematically searched electronic databases for studies containing radial head arthroplasty or radial head replacement and identified 19 studies for inclusion in the analysis. For each included study, a composite mean was obtained for Mayo Elbow Performance Score (MEPS) and range of motion. Outcomes were said to differ significantly if their confidence intervals did not overlap. The MEPS for acute treatment (90) was higher than that for delayed treatment (81). There was no difference in the pooled MEPS between the isolated (89) and complex injury pattern (87) groups or implant material. There was no difference in range of motion between the acute and delayed or isolated and complex groups, but the average degree of pronation was higher in patients treated with titanium implants (76°) compared with cobalt chromium implants (66°). This systematic review suggests that outcomes are improved following acute arthroplasty for treatment of radial head fractures compared with delayed treatment, based on MEPS. The lack of other significant differences detected is likely due to the significant heterogeneity and inadequate power in current studies. Further prospective studies isolating the different variables will be needed to determine their true effect on outcomes. [Orthopedics. 2016; 39(3):153-160.].

Management of Adult Elbow Fracture Dislocations

Elbow fracture dislocations are complicated injuries that are difficult to manage and fraught with complications. A complete series of radiographs is typically complemented with CT scan to evaluate the elbow and assist preoperative planning. Typically, operative intervention is necessary and a systematic approach to the elbow injuries should be chosen. This article addresses the coronoid and proceeds to the radial head, lateral soft tissues, and finally the medial ligaments if elbow instability persists. With a focused, systematic surgical approach, improved outcomes have been demonstrated and patients may recover full function and range of motion in the affected elbow.

Implications of radial head hemiarthroplasty dish depth on radiocapitellar contact mechanics

PURPOSE

To investigate the effect of radial head implant dish depth on radiocapitellar joint contact mechanics.

METHODS

Computed tomography images of 13 fresh-frozen cadaveric humeri were reconstructed into 3-dimensional finite element models with accurate cartilage geometry. Native humeri were paired with the corresponding native radial heads and axisymmetric radial head prosthesis models of the following dish depths: 1.0 mm, 1.5 mm, 2.0 mm, 2.5 mm, and 3.0 mm. Radiocapitellar contact mechanics were quantified at 4 different flexion angles (0°, 45°, 90°, and 135°) with a 100-N axial load applied to the radial head using a modeling protocol previously validated by cadaveric studies. The radial head was permitted to translate freely to its optimal position while the humerus was fully constrained. Output variables were contact area and peak contact stress.

RESULTS

All prostheses had significantly decreased contact area and increased peak contact stress at all flexion angles relative to the native radiocapitellar joint. Contact area increased with prosthesis dish depth until reaching a plateau with a predicted local maximum at a mean depth of 3.2 ± 0.7 mm. Peak contact stress was elevated for both the shallowest and deepest models and reached a predicted local minimum at a mean depth of 1.8 ± 0.3 mm.

CONCLUSIONS

Contact area and peak contact stress were dependent on radial head prosthesis dish depth. There was an optimal implant dish depth for radiocapitellar contact mechanics at approximately 2 mm.

CLINICAL RELEVANCE

Optimizing radiocapitellar contact mechanics using rigorous and systematic prosthesis design techniques may lead to better clinical outcomes due to reduced capitellar cartilage degradation.

Complications of radial head prostheses

Radial head prostheses are indicated for treatment of complex radial head fractures not amenable for fixation. After the initial experience with silastic implants, metallic or pyrocarbon arthroplasty have been used for 20 years. Little is known about complications related to these implants. Main complications are related to loosening whether they are cemented or not cemented. Hypotheses have been proposed like inadequate stem design, insufficient cement technique, stress shielding, and foreign body reactions secondary to polyethylene wear. Pain and stiffness are other common complications often related to oversized radial head component or overstuffing of the joint with excessive lengthening of the radius. Instability can be another complication in the context of more complex trauma with lateral collateral ligament complex lesion and coronoid fracture. Fixation of the coronoid fracture, reinsertion of the lateral collateral ligament complex, and the use of monobloc radial head prosthesis are recommended to stabilize the joint. Finally, osteoarthritis is common with follow-up.

Outcomes of bipolar radial head prosthesis to treat complex radial head fractures in 22 patients with a mean follow-up of 50 months

BACKGROUND

Radial head replacement is indicated to treat complex proximal radial fractures that are not amenable to internal fixation.

HYPOTHESIS

Implantation of a bipolar radial head prosthesis after radial head excision ensures stability of the elbow and forearm, thereby promoting ligament healing and restoring elbow function.

MATERIAL AND METHODS

Twenty-two patients managed with implantation of a bipolar radial head prosthesis (Guepar(®)) were evaluated after a mean follow-up of 50 months. The procedure was performed in the acute setting in 16 patients, including 13 with associated injuries; and at the stage of sequelae in 6 patients.

RESULTS

Prosthesis removal was required in 4 patients. Of the remaining 18 patients, 14 (77%) had satisfactory Mayo Elbow Performance Score values, 14 (77%) little or no functional impairment, and 11 (61%) little or no pain. Mean motion arcs were 100° in flexion-extension and 143° in pronation-supination. Mean elbow strength in flexion and mean wrist strength were 67% and 86%, respectively, of those on the contralateral normal side. Radio-lucent lines were visible around the prosthesis in 5 patients, radial neck osteolysis in 10 patients, and capitellar erosion in 7 patients. Seven patients each experienced a complication. Early revision surgery to treat elbow instability was required in 6 patients.

DISCUSSION

Outcomes after Guepar(®) bipolar radial head prosthesis implantation were disappointing in patients with complex radial head fractures seen in the acute or chronic setting. The associated injuries to bones and ligaments and the measures taken to repair them influence the prognosis. The complication rate is non-negligible and seems to increase over time.

LEVEL OF EVIDENCE

IV, retrospective study.

Treatment strategy of terrible triad of the elbow: experience in Shanghai 6th People's Hospital

BACKGROUND

Terrible triad of the elbow can be a challenging injury to treat, with a history of well-known complications. The purpose of this study is to report the outcomes of a modification of the standard surgical protocol for the repair of terrible triad of the elbow injuries.

METHODS

We retrospectively reviewed terrible triad of the elbow injuries treated at our hospital using a modified surgical technique. Our surgical procedure includes fixation or replacement of the radial head and repair of the ruptured lateral collateral ligament (LCL) through a lateral approach. Simultaneous fixation of the coronoid process and repair of the common flexor muscle and medial collateral ligament (MCL) injury were performed through an anteromedial incision. Mayo Elbow Performance Score (MEPS) was determined for each patient at the final clinic visit. The Broberg and Morrey classification was used for evaluating traumatic arthritis.

RESULTS

There were 21 patients (21 elbows) included in the analysis, and the mean follow-up period was 32 months (range, 24-48 months). At the last follow-up the mean flexion-extension arc of the elbow was 126° and the mean forearm rotation was 139°. The mean MEPS was 95 points (range, 85-100 points), with 19 excellent results and two good results. Concentric stability was restored in all cases. Two patients had heterotopic ossification, one patient had radial head nonunion, one patient had a superficial infection, and one patient had ulnar nerve neuropathy.

CONCLUSION

Our surgical strategy for terrible triad of the elbow has the advantage of providing both bony and soft-tissue stability simultaneously, thereby allowing active early motion as well as functional recovery of the elbow.

Functional outcomes post-radial head arthroplasty: a systematic review of literature

BACKGROUND

The present study was conducted to determine the quality and content of research on the functional outcomes and complications post-metal radial head arthroplasty (RHAP).

METHODS

A comprehensive search of medical databases for studies reporting on functional outcomes of patients undergoing metallic RHAP was conducted. The Structured Effectiveness Quality Evaluation Scale (SEQES) was used to evaluate quality of the studies.

RESULTS

We identified 21 Sackett's Level IV studies reporting on 391 radial heads. The mean duration of follow-up was 47.2 months and the mean (SD) age of patients was 48.4 years (6.9 years). The male to female ratio was found to be 1.05 : 1 and the dominant arm was involved in 54% of patients. When functional outcomes achieved post-RHAP were compared with normative scores, the comparison suggested that RHAP has good to excellent functional outcomes in short- to mid-term follow-up. The weighted mean (SD) Mayo Elbow Performance Score was 85.8 (4.1) (95% confidence interval 85.3 to 86.3). Incidences of implant removal (3.06%) and revision (2.22%) were found to be low.

CONCLUSIONS

There is consistent low-quality evidence of positive functional outcomes following RHAP. The heterogeneity of type of implant, patient characteristics and outcome measures used, along with an inadequate reporting of study details, restrict any definitive conclusions being made.

Radial head fractures: indications and outcomes for radial head arthroplasty

Radial head fractures without associated bony or ligamentous injury can be safely treated with internal fixation, if possible, or arthroplasty if nonreconstructable. However, nonreconstructable radial head fractures in association with elbow dislocation and/or ligamentous injury in the elbow or forearm represent a specific subset of injuries that requires restoration of the radiocapitellar articulation for optimal function. The purpose of this article was to summarize the indications for radial head arthroplasty and discuss the reported outcomes.

Open arthrolysis and prosthetic replacement of the radial head for elbow stiffness associated with rotation limitation

BACKGROUND

Limited forearm rotation is a frequent combined disorder in elbow stiffness. If the radial head cannot be saved during open arthrolysis, prosthetic replacement might be considered because it enhances stability and allows early motion.

METHODS

In this study we retrospectively analyzed the outcome of 8 patients (7 men, 1 woman) who underwent open arthrolysis and simultaneous prosthetic replacement after resection of the radial head to restore elbow range of motion and forearm rotation. Patients were a mean age of 31.7 years (range, 22-40 years).

RESULTS

Postoperatively, the mean (range) active range of motion improved from 29.4° (0°-70°) to 113.1° (80°-135°), mean (range) supination increased from 38.8° (0°-80°) to 77.5° (50°-90°), and mean (range) pronation improved from 18.8° (0°-80°) to 68.8° (50°-80°). The Mayo Elbow Performance Score improved from a mean (range) of 57.5 (50-70) to 92.5 (85-100) points. No elbow valgus instability was detected over a mean duration of 26 months of follow-up. The implant was considered stable in all patients.

CONCLUSIONS

Open arthrolysis and prosthetic replacement of the radial head are effective in treating elbow stiffness with associated rotation limitation after resection of the radial head.

The Essex-Lopresti lesion

The Essex-Lopresti lesion represents a severe injury of the forearm unit. In the 1940s, it’s pathology and consequences have already been mentioned by several authors. Over the course of time, the pathophysiology of the lesion was displayed in more detail. Therefore, an intensive analysis of the involved anatomic structures was done. The interosseous membrane was shown to play a major role in stabilising the forearm unit, in the situation of a fractured radial head, which is the primary stabiliser of the longitudinal forearm stability. Moreover, biomechanical analyses showed a relevant attribution of the distal radio-ulnar joint to the forearm stability. If, in the case of a full-blown Essex-Lopresti lesion, the radial head, the interosseous membrane and the distal radio-ulnar joint are injured, proximalisation of the radius will take place and will come along with secondary symptoms at the elbow joint and the wrist. According to actual studies, the lesion seems to occur more often than realised up to now. Thus, to avoid missing the complex injury, subtle clinical diagnosis combined with adequate imaging has to be undertaken. If the lesion is confirmed, several operative treatment options are available, yet not proofed to be sufficient.

Newly defined fracture pattern specific to Mason III radial head fractures: fracture description, management and outcomes using screw fixation

BACKGROUND

  Radial head fractures are the most common type of elbow fracture and are universally classified under the Mason classification system. Mason type III fractures are comminuted and are the most difficult to treat, generally requiring plating if possible, or more commonly arthroplasty or excision, which gives a variable outcome. We hypothesized that a new and specific fracture pattern of the radial head (Mason III) can be treated successfully with screw fixation.

METHODS

  Six patients presented to the senior surgeon's clinic with this unusual Mason III fracture pattern. In these patients, the fracture was acute, requiring an open reduction and internal fixation with the use of three headless compression screws. Average follow-up time was 21 months. Using serial X-rays and the Broberg-Morrey elbow score, the six acute fractures were evaluated radiologically and functionally.

RESULTS

  All six patients had good to excellent results using the Broberg-Morrey scoring system. All patients showed radiological and clinical union within 3 months of injury. No patient required revision surgery or excision at a later date.

DISCUSSION

  We have recognized a specific type of comminuted and displaced Mason III radial head fracture that has not previously been described in the literature. This type of fracture is amenable to open reduction internal fixation with buried compression screws giving a good to excellent outcome, while avoiding the common consequences seen with a radial head excision, arthroplasty or plate fixation.

The intra-operative radius joystick test to diagnose complete disruption of the interosseous membrane

Disruption of the interosseous membrane is easily missed in patients with Essex-Lopresti syndrome. None of the imaging techniques available for diagnosing disruption of the interosseous membrane are completely dependable. We undertook an investigation to identify whether a simple intra-operative test could be used to diagnose disruption of the interosseous membrane during surgery for fracture of the radial head and to see if the test was reproducible. We studied 20 cadaveric forearms after excision of the radial head, ten with and ten without disruption of the interosseous membrane. On each forearm, we performed the radius joystick test: moderate lateral traction was applied to the radial neck with the forearm in maximal pronation, to look for lateral displacement of the proximal radius indicating that the interosseous membrane had been disrupted. Each of six surgeons (three junior and three senior) performed the test on two consecutive days. Intra-observer agreement was 77% (95% confidence interval (CI) 67 to 85) and interobserver agreement was 97% (95% CI 92 to 100). Sensitivity was 100% (95% CI 97 to 100), specificity 88% (95% CI 81 to 93), positive predictive value 90% (95% CI 83 to 94), and negative predictive value 100%). This cadaveric study suggests that the radius joystick test may be useful for detecting disruption of the interosseous membrane in patients undergoing open surgery for fracture of the radial head and is reproducible. A confirmatory study in vivo is now required.

The Essex-Lopresti injury: More than just a pain in the wrist

As the scope of plastic surgical practice expands to include disorders of the carpus and wrist, it has become increasingly important for plastic surgeons to understand pathoanatomy that has not traditionally been considered an integral component of training. The Essex-Lopresti injury consists of a radial head fracture with associated injury to the forearm interosseus membrane and longitudinal instability of the distal radioulnar joint. Early recognition of this disorder usually results in a predictable and satisfactory outcome. However, when this disorder is unrecognized, late reconstruction is challenging and unpredictable, and treatment may be misdirected to the wrist alone if the forearm and elbow are not considered as a component of this injury. The present report describes the importance of examining the elbow in all cases of wrist pain. As well, the literature is reviewed regarding the differences in treatment of acute and chronic Essex-Lopresti injuries. As plastic surgeons become more involved in the treatment of wrist injuries, the conscientious practitioner should be aware of more complicated pathology that may present as a seemingly straightforward wrist problem.

Proximal radial drift following radial head resection

BACKGROUND

Proximal radial migration is a well-documented phenomenon after radial head resection, but there have been no studies evaluating other planes of proximal radial stump drift after resection. The purpose of this study is to evaluate the anatomic position of the radial stump in relation to the capitellum after radial head resection, and determine the factors affecting this position and long-term functional outcomes.

METHODS

Thirteen patients who had undergone radial head resection for a variety of injury patterns were identified and evaluated at a mean of 72 months postoperative. Each patient underwent a physical exam and outcome questionnaire evaluation (Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire, Mayo Elbow Performance Score [MEPS], and pain Visual Analog Scales [VAS] questionnaire). Anterior-posterior (AP) and lateral radiographs of the elbow were also performed.

RESULTS

The proximal radius resection length was an average of 18 mm (range, 11.1-31.9) compared to the nonoperative side. The proximal radial stump was determined to have significant migration both medially (P = .01) and posteriorly (P = .002) as compared to the opposite side as determined on the AP and lateral radiographs, respectively. Greater than 2 cm of proximal radial resection was associated with greater posterior drift (P = .03). Poorer MEPS were only correlated with an initial dislocation injury pattern (P = .02).

CONCLUSION

Radial head resection for fracture often leads to posterior and medial drift of the proximal radial stump, resulting in nonanatomic alignment with the capitellum. Increased resection greater than 2 cm resulted in larger amounts of drifting. Only a dislocation injury pattern was associated with worse functional outcomes.

Comminuted radial head fractures treated with pyrocarbon prosthetic replacement

PURPOSE

We had evaluated our experience in the treatment of displaced and comminuted radial head fractures with pyrocarbon radial head prosthesis.

METHODS

From May 2003 to July 2008, radial head prostheses were performed in 47 patients. There were 29 female and 18 male with mean age 51 (34-70 years). The follow-up was a mean of 48 (12-60 months). Fractures of the radial head have been classified by Hotchkiss. The indications for a radial head replacement were type III fractures in 27 cases, type IV fractures in ten cases, comminuted radial fracture associated with disruption of the medial collateral ligament in three cases, Monteggia variant in five cases, and Essex-Lopresti in two cases. Functional outcomes were assessed by visual analog scales (VAS) of pain, joint motion and stability, and using the Mayo Elbow Performance Index.

RESULTS

The mean VAS score for elbow pain was 1 (0.5-2.1). Patients showed an average arc of motion from 6° to 140°, with 75° of pronation and 67° of supination. By using the Mayo Elbow Performance Index, 42 patients had good/excellent results, with three fair and two poor outcomes. Complications were two implant dislocations, one elbow stiffness, one dissociation of the implant, one stem rupture, and two posterior interosseous nerve palsy that recovered from 5 to 8 weeks. We had not seen persistent instability, infection, synostosis, severe degenerative changes, or impingement.

CONCLUSIONS

The treatment of comminuted radial head fracture with pyrocarbon implant usually gives an optimal result depending on the severity of the initial injury and the presence of associated lesions. The size of the prosthesis is often overestimated, causing restriction in motion due to impingement, overstuffing, or dislocations.

Anterior Elbow Subluxation after Radial Head Arthroplasty for Fracture Dislocation of the Elbow

We describe a case of elbow dislocation with Hotchkiss type III radial head fracture and Regan-Morrey type II coronoid process fracture, which was treated with radial head replacement. It was complicated with oversizing of prosthesis, resulting in elbow subluxation. It was treated with radial shaft shortening osteotomy. The clinical result was satisfactory.

Mid- to long-term results after bipolar radial head arthroplasty

BACKGROUND

Radial head arthroplasty is considered the treatment of choice for unreconstructable radial head fractures in the acute fracture situation. Although short-term results in the current literature are promising, replacement of the radial head remains controversial as long-term results are still missing. We report our 8.8-year results after treatment with a bipolar radial head prosthesis by Judet.

MATERIALS AND METHODS

In our department, 19 patients were treated with bipolar radial head arthroplasty between 1997 and 2001. Seventeen of these patients-14 men and 3 women-were examined retrospectively after 106 months (range, 78-139). Of these, 9 patients were treated primarily, 7 patients secondarily, and 1 because of a tumor.

RESULTS

On the Mayo Elbow Performance Score, 6 patients achieved excellent results, 10 good, and one fair. The mean DASH score was 9.8 (range, 0-34). No differences were seen between primary and secondary implantation. Flexion averaged 124° (range, 110-150°), the extension deficit was 21° (range, 0-40°), pronation 64° (range, 30-90°), and supination 64° (range, 30-90°). The following complications were seen: 2 dislocations and 8 cases of degenerative changes of the capitellum, 1 with severe erosion. Signs of ulnohumeral arthrosis were found in 12 patients. No evidence of loosening, radiolucencies, or proximal bone resorption was detected.

CONCLUSION

Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis.

Screw fixation of radial head fractures: compression screw versus lag screw--a biomechanical comparison

INTRODUCTION

Secondary loss of reduction and pseudarthrosis due to unstable fixation methods remain challenging problems of surgical stabilisation of radial head fractures. The purpose of our study was to determine whether the 3.0mm Headless Compression Screw (HCS) provides superior stability to the standard 2.0 mm cortical screw (COS).

MATERIALS AND METHODS

Eight pairs of fresh frozen human cadaveric proximal radii were used for this paired comparison. A standardised Mason II-Fracture was created with a fragment size of 1/3 of the radial head's articular surface that was then stabilised either with two 3.0 mm HCS (Synthes) or two 2.0 mm COS (Synthes) according to a randomisation protocol. The specimens were then loaded axially and transversely with 100 N each for 4 cycles. Cyclic loading with 1000 cycles as well as failure load tests were performed. The Wilcoxon test was used to assess statistically significant differences between the two groups.

RESULTS

No statistical differences could be detected between the two fixation methods. Under axial loads the COS showed a displacement of 0.32 mm vs. 0.49 mm for the HCS. Under transverse loads the displacement was 0.25 mm for the COS vs. 0.58 mm for the HCS group. After 1000 cycles of axial loading there were still no significant differences. The failure load for the COS group was 291 N and 282 N for the HCS group.

CONCLUSION

No significant differences concerning the stability achieved by 3.0 mm HCS and the 2.0 mm COS could be detected in the experimental setup presented.

The acute bipolar radial head replacement for isolated unreconstructable fractures of the radial head

For the acute treatment of radial head fractures, radial head arthroplasty can be considered if open reduction and internal fixation is not technically possible and if simple radial head resection is contraindicated. We report our experience with a bipolar Judet radial head prosthesis. After a mean follow-up of 41.7 months, 16 patients were assessed following radial head replacement. The outcome was assessed clinically, functionally, and radiographically. Outcome was satisfactory in 87.5% of cases. The mean post-operative ranges of motion were greater than the functional arcs both in flexion-extension and in pronation-supination, and the results did not appear to be influenced in a significant way by the type of original lesion. All elbows were stable. The main complication was the development of heterotopic ossifications. Bipolar radial head prosthesis represents a suitable option for acute treatment of unreconstructable radial head fractures, either isolated or associated with elbow dislocation and in the absence of other bony lesions.

Radial head arthroplasty

Radial head arthroplasty remains an encouraging treatment option for comminuted radial head fractures in an unstable elbow or forearm. This article discusses the surgical considerations related to radial head arthroplasty, including anatomy, indications, and surgical technique. Radial head arthroplasty outcomes literature and a review of current implant options are also discussed.

Failure of the interosseous membrane to heal with immobilization, pinning of the distal radioulnar joint, and bipolar radial head replacement in a case of Essex-Lopresti injury: case report

The authors report a case of a patient with complex radial head and ulnar shaft fractures with an associated tear of the interosseous membrane, which failed to heal despite open reduction internal fixation of the ulna, a bipolar radial head replacement, and cross pinning of the distal radioulnar joint. This case demonstrates that failure of the interosseous membrane can occur even in a properly replaced bipolar radial head with adequate immobilization of the forearm and pinning of the distal radioulnar joint.

Radiolucencies surrounding a smooth-stemmed radial head component may not correlate with forearm pain or poor elbow function

HYPOTHESIS

Radiolucencies surrounding the stems of smooth-stemmed metal radial head prostheses placed for comminuted radial head fractures are associated with proximal radial forearm pain.

MATERIALS AND METHODS

Patients in whom 18 consecutive elbows that underwent metal radial head replacement with smooth stems for comminuted radial head fractures were assessed at least two years after surgery. Proximal radial forearm pain was assessed with a visual analog score (0-10) and elbow function with a Mayo index. "Mean stem radiolucency" was determined by two musculoskeletal radiologists based upon three radiographs of each elbow: a lateral in maximum extension, a lateral in maximum flexion, and an antero-posterior.

RESULTS

All elbows were stable and stem radiolucencies were present in 16 of the 17 available for study. "Mean stem radiolucency" did not correlate with proximal radial forearm pain (p = 0.63) or Mayo scores (p = 0.37) using Spearman's correlation coefficients. 6/17 prostheses were in patients that rated their pain level as 0; 11/17 were in patients that rated their pain as at least 1 with 5 being the highest. Using the Signed Rank test, operative elbows had less motion for both flexion/extension (p = 0.0001) and pronation/supination (p = 0.01) compared to non-operative elbows from the same patient.

DISCUSSION

"Mean stem radiolucency" did not correlate with proximal radial forearm pain. However, proximal radial forearm pain was present in 11/17 elbows based upon visual analog scores. Proximal radial forearm pain in this population may have several etiologies.

CONCLUSION

"Mean stem radiolucencies" surrounding smooth-stemmed metal radial head prostheses for fractures did not correlate with proximal radial forearm pain scores.

LEVEL OF EVIDENCE

Level 4; Retrospective case series, no control group.

Optimizing elbow rehabilitation after instability

Elbow instability is a common clinical problem that requires careful assessment and treatment to achieve a successful outcome. Rehabilitation is a key element in achieving a stable mobile elbow. Careful communication between the treating therapist and surgeon is essential so that an optimal rehabilitation program can be developed and implemented. By understanding the patterns of injury and the biomechanics of the elbow, a good outcome can be achieved in most patients who have elbow instability.

Chronic posttraumatic elbow disorders treated with metallic radial head arthroplasty

BACKGROUND

Metallic radial head arthroplasty is a proven technique for the treatment of complex radial head fractures. The purpose of this study was to evaluate the functional outcomes of a metallic radial head arthroplasty in patients with chronic posttraumatic elbow disorders.

METHODS

The results of thirty-two metallic radial head arthroplasties in thirty-two consecutive patients were retrospectively reviewed. The indications for the radial head arthroplasty included posttraumatic nonunion and malunion of the radial head, elbow instability following previous excision of the radial head, and failure of a silicone radial head implant used to treat an acute radial head fracture. The study included thirteen male and nineteen female patients followed for a minimum of two years. The radial head arthroplasties were performed at an average of 2.4 years after the injury. Analysis included chart review, personal interview, physical examination, radiographic examination, and strength testing as well as the administration of general and region-specific questionnaires.

RESULTS

The mean duration of follow-up was eight years. The average Mayo Elbow Performance Score was 83 of 100 points, with seventeen (53%) of the thirty-two results rated as excellent; four (13%), as good; seven (22%), as fair; and four (13%), as poor. The average score for subjective patient satisfaction was 8.5 points on a 10-point scale. Patients had significantly less motion and strength in the affected elbow than in the unaffected elbow. Seventy-four percent of the patients demonstrated some degree of posttraumatic arthritis. There were no significant differences in ulnar variance and the ulnohumeral joint space between the affected and unaffected arms. Over the course of the study, no metallic radial head arthroplasties required revision.

CONCLUSIONS

Metallic radial head arthroplasty for the treatment of posttraumatic elbow disorders appears to be a safe and durable procedure that can provide a functional range of motion and pain relief for at least five to ten years. However, longer follow-up is needed to evaluate progression of lucencies adjacent to stems and osteoarthritis.

Complex elbow instability

This article attempts to outline the most current relevant literature regarding diagnosis, pathoanatomy, and treatment options for complex elbow instability. Specific attention is directed toward unique injury patterns, important biomechanical principles, and recent clinical outcome studies. Directions for future research are suggested.

Reconstruction of essex-lopresti injury of the forearm: technical note

Longitudinal instability of the forearm resulting from an Essex-Lopresti injury is a surgical challenge, and no technique has yet met universal success. A new technique is presented here consisting of reconstruction of the radial head, leveling of the distal radioulnar joint, reconstruction of the central band of the interosseous membrane by using a pronator teres rerouting technique, and finally repair of the triangular fibrocartilage complex. It is hoped that by addressing all of the contributing longitudinal stabilizing structures, the longitudinal instability of the forearm will be controlled. The technique is challenging and requires much surgical experience.

Reconstruction of a Mason type-III fracture of the radial head using four different fixation techniques

We have evaluated four different fixation techniques for the reconstruction of a standard Mason type-III fracture of the radial head in a sawbone model. The outcome measurements were the quality of the reduction, and stability.

A total of 96 fractures was created. Six surgeons were involved in the study and each reconstructed 16 fractures with 1.6 mm fine-threaded wires (Fragment Fixation System (FFS)), T-miniplates, 2 mm miniscrews and 2 mm Kirschner (K-) wires; four fractures being allocated to each method using a standard reconstruction procedure.

The quality of the reduction was measured after definitive fixation. Biomechanical testing was performed using a transverse plane shear load in two directions to the implants (parallel and perpendicular) with respect to ultimate failure load and displacement at 50 N.

A significantly better quality of reduction was achieved using the FFS wires (Tukey’s post hoc tests, p < 0.001) than with the other devices with a mean step in the articular surface and the radial neck of 1.04 mm (sd 0.96) for the FFS, 4.25 mm (sd 1.29) for the miniplates, 2.21 mm (sd 1.06) for the miniscrews and 2.54 mm (sd 0.98) for the K-wires. The quality of reduction was similar for K-wires and miniscrews, but poor for miniplates.

The ultimate failure load was similar for the FFS wires (parallel, 196.8 N (sd 46.8), perpendicular, 212.5 N (sd 25.6)), miniscrews (parallel, 211.8 N (sd 47.9), perpendicular, 208.0 N (sd 65.9)) and K-wires (parallel, 200.4 N (sd 54.5), perpendicular, 165.2 N (sd 37.9)), but significantly worse (Tukey’s post hoc tests, p < 0.001) for the miniplates (parallel, 101.6 N (sd 43.1), perpendicular, 122.7 N (sd 40.7)). There was a significant difference in the displacement at 50 N for the miniplate (parallel, 4.8 mm (sd 2.8), perpendicular, 4.8 mm (sd 1.7)) vs FFS (parallel, 2.1 mm (sd 0.8), perpendicular, 1.9 mm (sd 0.7)), miniscrews (parallel, 1.8 mm (sd 0.5), perpendicular, 2.3 mm (sd 0.8)) and K-wires (parallel, 2.2 mm (sd 1.8), perpendicular, 2.4 mm (sd 0.7; Tukey’s post hoc tests, p < 0.001)).

The fixation of a standard Mason type-III fracture in a sawbone model using the FFS system provides a better quality of reduction than that when using conventional techniques. There was a significantly better stability using FFS implants, miniscrews and K-wires than when using miniplates.

Fractures of the radial head and neck: current concepts in management

Despite advances in surgical techniques, fractures of the radial head are challenging to manage. Most radial head fractures can be managed nonsurgically, with emphasis on early motion to achieve good results. Treatment of more complex radial head fractures, however, especially those associated with elbow instability, remains controversial. The choice for such injury is between open reduction and internal fixation and arthroplasty. Modern implants and techniques have led to improvements in both of these technically demanding procedures. With proper care and understanding of the mechanism of elbow function, better long-term results can be achieved. The current literature suggests that the Mason classification guides choice of the best treatment modality to achieve optimal long-term function. Fracture complexity also should be used as a guide when selecting treatment, and proper surgical technique is critical for success.

Lateral ulnohumeral joint space widening is not diagnostic of radial head arthroplasty overstuffing

PURPOSE

Metallic radial head replacement with a prosthesis that is too thick has been reported to be associated with stiffness, pain, and capitellar wear. Radiographic widening of the lateral ulnohumeral joint after radial head replacement has been used as a criterion to diagnose overstuffing. The purpose of this study was to show that widening of the lateral ulnohumeral joint is a normal anatomic variant and therefore cannot be used conclusively to diagnose joint overstuffing.

METHODS

Fifty normal standardized anteroposterior radiographs from 50 patients were reviewed to evaluate variations in the joint space between the medial and lateral ulnohumeral joints. Measurements were taken on 3 occasions by one surgeon and on a single occasion by a second surgeon. At 4-times magnification, 2 lines were drawn perpendicular to the lateral ulnohumeral joint and 2 lines perpendicular to the medial ulnohumeral joint. Measurements were then compared to evaluate joint space width and parallelism.

RESULTS

Intraclass correlation coefficients indicated excellent intrarater and interrater reliability. The width of the lateral ulnohumeral joint space was greater than that of the medial ulnohumeral joint space. The medial joint space was parallel, and the lateral joint space was nonparallel.

CONCLUSIONS

The lateral ulnohumeral joint space is often wider than the medial ulnohumeral joint space on anteroposteror radiographs of the normal elbow. Although the medial joint space is usually parallel, the lateral joint space may be nonparallel and wider laterally; therefore, lateral joint space widening is not a reliable indicator of radiocapitellar joint overstuffing. A nonparallel medial ulnohumeral joint space may suggest possible overstuffing of a radial head arthroplasty; however, comparing radiographs of the uninjured elbow is likely the best investigation to consider when overstuffing is suspected.