Radial Head Arthroplasty in the Active Duty Military Service Member With Minimum 2-Year Follow-Up

Radial Head Fractures: Current Trends in Treatment and Outcomes, A Retrospective Review

BACKGROUND

Radial head fractures are common elbow fractures in adults, and their treatment algorithm remains controversial. Particularly with displaced Mason III or IV radial head fractures, studies have shown mixed results when comparing outcomes between radial head arthroplasty (RHA) and open reduction internal fixation (ORIF). Although multifactorial, patient characteristics often play a large role in treatment modality. The purpose of this study was to analyze the current trend in the management of radial head fractures, complications, and need for repeat operation among these groups.

MATERIALS AND METHODS

We conducted a retrospective database review using the IBM Truven MarketScan Databases and analyzing all available patients treated for radial head fractures between 2015 to 2020. Patients were grouped by treatment modality, including nonoperative, ORIF, radial head excision (RHE), and RHA. Patient characteristics, complication rates, reoperation rates, and predictive factors for undergoing surgery were assessed.

RESULTS

Our search yielded 18,945 cases of radial head fractures that underwent treatment. The majority of patients were managed nonoperatively (16,035), and fewer were treated via ORIF, RHA, and RHE (1,636, 1,174, and 100, respectively). Of these, between 1% and 2.5% of patients in each group underwent revision surgery.

CONCLUSION

We found that patients who undergo RHA or RHE are typically older and have more comorbidities compared to patients who are treated nonoperatively or undergo ORIF. We found no significant difference in reoperation rates based on initial mode of treatment. Male sex, osteoporosis, coronary artery disease, and a displaced fracture are predictive of undergoing surgery for a radial head fracture. [Orthopedics. 202x;4x(x):xx-xx.].

Heterotopic ossification following severe radial head fractures: Clinical outcome and associated factors

OBJECTIVES

This study aimed to evaluate clinical outcome, prevalence, severity, location, range of motion, and possible risk factors of heterotopic ossification (HO) following severe radial head fractures.

PATIENTS AND METHODS

In this retrospective study, 73 patients (40 males, 33 females; mean age: 51.4±15 years; range, 20 to 82 years) with Mason-Johnston type 3 and 4 radial head fractures were surgically treated with osteosynthesis or radial head arthroplasty (RHA) between September 2014 and February 2021. Fifty-one were examined in person, while 22 participated via questionnaire. The clinical outcome was assessed by the range of motion, the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), and the 36-item Short-Form Health Survey (SF-36). Operative and postoperative details and the intake of HO prophylaxis were reviewed. Heterotopic ossification severity and location was evaluated on radiographs.

RESULTS

Heterotopic ossification was present in 52.1%, while in 31.5% of all participants, RHA was needed. Overall, 46.6% received additional ligamental refixation. The mean time to surgery was 8.9±11.9 days, and the mean DASH was 13.7±16.6. In patients treated with osteosynthesis, more HO was observed for Mason-Johnston type 4 injuries compared to Mason-Johnston type 3 injuries (p=0.028). Overall, more HO was present in Mason-Johnston type 4 injuries (63.6%) compared to Mason-Johnston type 3 injuries (42.5%), without reaching significance (p=0.072). No significant association between HO and time to surgery (p=0.716), implantation of RHA (p=0.127), or ligamental refixation (p=0.121) was detected. Regardless of intake of HO prophylaxis, nearly the same amount of HO (51.7% vs. 53.8%) was present. No differences between the HO and non-HO group were detected in the DASH (p=0.553) and the SF-36 (physical component, p=0.728; mental component, p=0.275).

CONCLUSION

Over 50% surgically treated radial head fractures classified as Mason-Johnston types 3 and 4 developed HO, while more severe injuries led to a higher prevalence of HO. No increased rates of HO were determined for delayed surgery, surgical treatment methods, and use of HO prophylaxis. Therefore, regular HO prophylaxis might not be needed. Additionally, no significant differences in functional scores and quality of life were detected between patients with and without HO.

Mid-term outcome following radial head arthroplasty in acute trauma: risk factors for poor outcome

BACKGROUND

The aims of this study were to evaluate the outcomes of a single type of radial head implant in a large cohort of patients at mid-term follow-up and to determine the associated risk factors for inferior functional outcomes.

METHODS

We performed a retrospective follow-up assessment of 65 patients (33 women and 32 men; mean age, 53.3 years [range, 22-81 years]) who underwent radial head arthroplasty (RHA) for acute trauma between 2012 and 2018, after a minimum follow-up period of 3 years. The Mayo Elbow Performance Score, Oxford Elbow Score, Disabilities of the Arm, Shoulder and Hand score, and Mayo Modified Wrist Score were evaluated, and all available radiographs were analyzed. All complications and revision procedures were assessed. Bivariate and multivariate regression analyses were performed to identify potential risk factors for a poor outcome following RHA.

RESULTS

After an average follow-up period of 4.1 years (range, 3-9.4 years), the mean Mayo Elbow Performance Score was 77.2 (standard deviation [SD], 18.9); mean Oxford Elbow Score, 32.0 (SD, 10.6); mean Mayo Modified Wrist Score, 74.6 (SD, 13.7); and mean Disabilities of the Arm, Shoulder and Hand score, 29.0 (SD, 21.2). Average range of motion measured 10° (SD, 15°) in extension, 125° (SD, 14°) in flexion, 81° (SD, 14°) in pronation, and 63° (SD, 24°) in supination. The overall complication and reoperation rates were 38.5% and 30.8%, respectively, with severe elbow stiffness being the most common reason for revision. Patient age >50 years, the use of an external fixator, the presence of accompanying medial collateral ligament injuries, and the development of higher-grade osteoarthritis were associated with a poor outcome.

CONCLUSION

Satisfactory medium-term outcomes can be achieved using a monopolar, long-stemmed RHA in patients with acute trauma. However, complication and revision rates are high, frequently leading to inferior outcome scores. Additionally, a higher patient age, the use of an external fixator, the presence of accompanying medial collateral ligament injuries, and the occurrence of higher-grade osteoarthritis were associated with a poor outcome; these factors should raise awareness by the treating trauma surgeon.

The comparative performance of radial head prostheses in patients younger than and older than 50 years: a systematic review

Background

Patient age may play a role in the surgeon's decision between radial head arthroplasty (RHA) and open reduction internal fixation in radial head fracture treatment. Though large sample reports have detailed outcomes of radial head replacement for a mean age younger than 50 years, the age ranges are widely distributed. Patient outcomes are not uniform across a broad age distribution. Therefore, treatment decisions should be evaluated within the confines of a narrower age bracket. An understanding of clinical outcomes for radial head replacement in younger adults will provide value for guiding treatment decisions. We performed a systematic review comparing the clinical outcomes for radial head replacement in patients younger and older than 50 years of age. Further analysis compared outcomes between RHA performed as a primary procedure and as a secondary procedure in patients younger and older than 50 years of age.

Methods

PubMed was queried for articles which delineated individual patient data for age, surgical treatment, and appropriate outcome metrics. Articles were grouped based on patient age of under 50 and over 50 years and within those age groups, based on the arthroplasty being performed as a primary or as a secondary procedure.

Results

There were no significant differences between the under 50 and the over 50 groups for Mayo Elbow Performance Score (P = .79) and for implant revision/removal (P = .32). In the under 50 group, RHA done as a primary procedure had significantly higher (P = .001) mean Mayo Elbow Performance Score than RHA done as a secondary procedure. In the over 50 group, relative risk was 2.39 (95% confidence interval, 2.12-2.69) for implant revision/removal (P = .11) when comparing primary and secondary procedures.

Discussion

At a mean follow-up of 48 months, RHA in patients under the age of 50 years had satisfactory outcomes which were comparable to outcomes in patients over the age of 50 years. Across both age groups, arthroplasty performed as a primary procedure demonstrated superior outcomes compared to arthroplasty performed as a secondary procedure. Our findings provide guidance to surgeons who face a multifaceted decision when encountering younger adult patients with radial head fracture patterns that may not be amenable to fixation. Awareness of the age-specific performance of radial head implants is an important component of the decision for surgical treatment.

Is Self-reported Return to Duty an Adequate Indicator of Return to Sport and/or Return to Function in Military Patients?

BACKGROUND

In the military, return-to-duty status has commonly been used as a functional outcome measure after orthopaedic surgery. This is sometimes regarded similarly to return to sports or as an indicator of return to full function. However, there is variability in how return-to-duty data are reported in clinical research studies, and it is unclear whether return-to-duty status alone can be used as a surrogate for return to sport or whether it is a useful marker for return to full function.

QUESTIONS/PURPOSES

(1) What proportion of military patients who reported return to duty also returned to athletic participation as defined by self-reported level of physical activity? (2) What proportion of military patients who reported return to duty reported other indicators of decreased function (such as nondeployability, change in work type or level, or medical evaluation board)?

METHODS

Preoperative and postoperative self-reported physical profile status (mandated physical limitation), physical activity status, work status, deployment status, military occupation specialty changes, and medical evaluation board status were retrospectively reviewed for all active-duty soldiers who underwent orthopaedic surgery at Madigan Army Medical Center, Joint Base Lewis-McChord from February 2017 to October 2018. Survey data were collected on patients preoperatively and 6, 12, and 24 months postoperatively in all subspecialty and general orthopaedic clinics. Patients were considered potentially eligible if they were on active-duty status at the time of their surgery and consented to the survey (1319 patients). A total of 89% (1175) were excluded since they did not have survey data at the 1 year mark. Of the remaining 144 patients, 9% (13) were excluded due to the same patient having undergone multiple procedures, and 2% (3) were excluded for incomplete data. This left 10% (128) of the original group available for analysis. Ninety-eight patients reported not having a physical profile at their latest postoperative visit; however, 14 of these patients also stated they were retired from the military, leaving 84 patients in the return-to-duty group. Self-reported "full-time duty with no restrictions" was originally used as the indicator for return to duty; however, the authors felt this to be too vague and instead used soldiers' self-reported profile status as a more specific indicator of return to duty. Mean length of follow-up was 13 ± 3 months. Eighty-three percent (70 of 84) of patients were men. Mean age at the preoperative visit was 35 ± 8 years. The most common surgery types were sports shoulder (n = 22) and sports knee (n = 14). The subgroups were too small to analyze by orthopaedic procedure. Based on active-duty status and requirements of the military profession, all patients were considered physically active before their injury or surgery. Return to sport was determined by asking patients how their level of physical activity compared with their level before their injury (higher, same, or lower). We identified the number of other indicators that may suggest decreased function by investigating change in work type/level, self-reported nondeployability, or medical evaluation board. This was performed with a simple survey.

RESULTS

Of the 84 patients reporting return to duty at the final follow-up, 67% (56) reported an overall lower level of physical activity. Twenty-seven percent (23) reported not returning to the same work level, 32% (27) reported being nondeployable, 23% (19) reported undergoing a medical evaluation board (evaluation for medical separation from the military), and 11% (9) reported a change in military occupation specialty (change of job description).

CONCLUSION

Return to duty is commonly reported in military orthopaedics to describe postoperative functional outcome. Although self-reported return to duty may have value for military study populations, based on the findings of this investigation, surgeons should not consider return to duty a marker of return to sport or return to full function. However, further investigation is required to see to what degree this general conclusion applies to the various orthopaedic subspecialties and to ascertain how self-reported return to duty compares with specific outcome measures used for particular procedures and subspecialties.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

The Unsalvageable Radial Head in Patients Aged 30 Years and Younger

PURPOSE

Concern exists regarding the use of radial head arthroplasty (RHA) in younger patients. This study assessed clinical, functional, and radiographic outcomes of RHA in patients aged 30 years and younger.

METHODS

A retrospective review identified 26 elbows that underwent a smooth stem modular RHA in patients aged 30 years and younger at a median follow-up of 3.3 years clinically and 2.9 years radiographically. The mean age was 24 ± 5 years. Indications were acute trauma in 13 patients and chronic pathologies in the remaining 13, and these 2 groups were evaluated separately. Patients underwent clinical, functional, and radiographic evaluation.

RESULTS

Average arc of motion was 137° ± 16° in the cohort with acute trauma and 120° ± 24° in the cohort with chronic pathologies. Mean Patient-Rated Elbow Evaluation scores were 23 ± 18 (acute) and 31 ± 19 (chronic). Mean Quick Disabilities of the Arm, Shoulder, and Hand scores were 18 ± 15 (acute) and 23 ± 20 (chronic). Average Mayo Elbow Performance Index scores were 90 ± 9 (acute) and 80 ± 13 (chronic). Severe capitellar erosion was present in 1 patient (4%) in the cohort with chronic pathologies. Radiographic stem lucency was seen in all cases with 10 of these (38%) graded as severe. Moderate-to-severe ulnohumeral arthritis developed in 4 patients (15%), 3 of whom were in the chronic reconstruction group. Two patients (8%) required reoperation, 1 for persistent instability and 1 for stiffness, both in the cohort with chronic pathologies.

CONCLUSIONS

For acute trauma and challenging chronic conditions involving the radial head in patients aged 30 years and younger, a smooth stem modular RHA is an option. Although reoperation rates based on this series are low, osteoarthritis is common when used for posttraumatic conditions and severe radiographic stem lucency was seen in greater than one-third of patients. These concerning features warrant close follow-up, and further long-term outcomes are needed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Incidence of Pelvic Ring Fractures in the U.S. Military Population

Introduction 

Pelvic ring fractures occur frequently among the elderly population, but some studies demonstrate a bimodal distribution where the incidence is elevated among younger age groups as well. The mechanisms of injury also vary based on age groups. Previous studies are specific to trauma registries and centers, but epidemiological data within the U.S. military are sparse. In the U.S. military population, pelvic ring fractures can be related to high-energy trauma including motor vehicle accidents and combat warfare. The purpose of this study was to determine the incidence of pelvic ring fractures among active duty U.S. military service members between 2006 and 2015, while also describing the demographics associated with the findings.

Materials and Methods

All data were collected from the U.S. Defense Medical Epidemiology Database (DMED). To calculate the incidence rates, only first-time occurrences for pelvic ring fractures among military members were used. Each point was identified using International Classification of Diseases, Ninth Revision (ICD-9), clinical modification code 808 for “fractures of the pelvis.” A multivariate Poisson regression analysis was used to estimate the incidence rate per 1,000 person-years and 95% confidence intervals while controlling for sex, race, age, rank, and service. Rate ratios were calculated using different referent factors based on differences in sex, race, age, rank, and service branch. This study was IRB exempt as all the data used were de-identified patient data from the DMED system.

Results

Over the 10-year study period, a total of 4,802 incident cases of pelvic ring fractures, and a total of 13,748,429 person-years were documented. The overall incidence rate of pelvic ring fractures was 0.35 per 1,000 person-years. The incidence of pelvic ring fractures was highest among the youngest age group (<20 years) and among the lower-ranking service members. Additionally, other demographic groups such as the White race, female sex, and Army service members showed the highest incidence rates.

Conclusion

Our study determined baseline epidemiological data on incidence rates of pelvic ring fractures in the U.S. military. Patient demographics may be contributing factors, and the present analysis was able to elucidate associated underlying demographics. We demonstrated that the incidence was highest among the younger age groups, and that incidence rates may be specific to age cohorts. This study also found that lower-ranking service members had the highest incidence in all service branches, suggesting a form of occupational risk. Furthermore, our findings suggest that females, White race groups, and Army enlisted service members show a significantly higher incidence rate and may be at a greater risk. Our findings are important as they broaden the understanding of the patterns of pelvic ring fractures in the U.S. military population and occupational risks associated with this population.

Low return-to-sports rate after elbow injury and treatment with radial head arthroplasty

BACKGROUND

The aim of this study was to analyze sports participation after radial head arthroplasty among recreational athletes.

METHODS

A total of 57 recreational athletes (mean age, 49 years; age range, 18-79 years) treated with radial head arthroplasty for non-reconstructible radial head fractures were included in this retrospective study. The return-to-sports rate and the time to return to sports were analyzed. The clinical and radiologic outcomes were compared between patients who returned to sports (group 1) and those who did not (group 2).

RESULTS

After a mean follow-up period of 8.4 years (range, 2.5-16.4 years), 30 of 57 patients (53%) had returned to sports. The mean sports frequency significantly decreased from 5.2 ± 5.0 h/week to 2.2 ± 2.9 h/week after surgery (P < .001). In group 1, 83% of patients returned to the same sports activity whereas 17% changed to a less demanding sports activity. The mean time to return to sports was 158 days (range, 21-588 days). Patients who returned to sports had a significantly better Mayo Elbow Performance Score (MEPS) (84 ± 19 points vs. 63 ± 20 points, P < .001); Disabilities of the Arm, Shoulder and Hand score (16 ± 17 vs. 46 ± 22, P < .001); and arc of flexion (114° ± 32° vs. 89° ± 36°, P = .007). A secondary radial head prosthesis (P = .046) and MEPS lower than 85 points (P = .001) were associated with a significantly lower return-to-sports rate. No differences regarding radiographic changes were found between the 2 groups (P ≥ .256).

CONCLUSION

The return-to-sports rate after radial head replacement is low. A secondary radial head prosthesis and a worse clinical outcome (MEPS < 85 points) significantly increase the risk of not returning to sports after radial head arthroplasty.

Incidence of Cubital Tunnel Syndrome in the U.S. Military Population

PURPOSE

Cubital tunnel syndrome (CuTS) is the second most common peripheral nerve entrapment syndrome. However, existing epidemiological evidence regarding the estimated incidence of the CuTS disease burden in specific populations is sparse, especially among the U.S. military. The purpose of this study was to describe the demographics and determine the incidence of CuTS among active duty U.S. military service members.

METHODS

All first-time occurrences for CuTS among military members were identified using International Classification of Diseases, Ninth Revision, clinical modification code 354.2 for ulnar nerve lesions in the U.S. Defense Medical Epidemiology Database. A multivariable Poisson regression analysis was used to estimate the incidence rate ratio (IRR) per 1,000 person-years and 95% confidence intervals (95% CI), while controlling for sex, race, age, rank, and service. Rate-ratios were calculated using different referent factors based on differences in sex, race, age, rank, and service branch.

RESULTS

During the 10-year study period, the total number of incident cases of CuTS was 31,568, and a total of 13,745,456 person-years were documented. The overall unadjusted IRR of CuTS during the study period was 2.3 per 1,000 person-years (95% CI, 2.27-2.33). The 35- to 39-year age group had the highest adjusted IRR of CuTS. In addition, females, Caucasians, and junior enlisted service members showed significantly higher IRRs.

CONCLUSIONS

Our study was able to provide baseline epidemiological data on IRRs and influential risk factors in CuTS. We demonstrated an incidence of CuTS that is comparable with previously reported IRRs, which have varied from 0.08 to 8.0 cases per 1,000 person-years. This study also found significantly higher risk for the development of CuTS with increased age and among U.S. Army service members.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Shoulder and Elbow Fractures in Athletes

PURPOSE OF REVIEW

The purposes of this review are to discuss the management of shoulder and elbow fractures in athletes to optimize the return to sport and to highlight treatment impact on the return to play.

RECENT FINDINGS

Fractures of the shoulder and elbow can have profound implications in an athlete career. Recent technique of fractures management trended toward to preserve soft tissue which is critical for an early recovery in athletic population. Arthroscopy presents a strong interest for the treatment of intra-articular fracture, and minimally invasive approach as developed in humeral shaft fracture can be considered to avoid soft tissue damage. Non-articular, stable, and minimally displaced fractures are mainly treated conservatively. However, we encourage a more aggressive approach in shoulder and elbow injuries in the athletes including minimally invasive and stable fixation to preserve vascularity and muscle environment.

Anthropometric Study of the Radiocapitellar Joint

PURPOSE

There is scant knowledge about the relationship between the size of the radial head and the size of the capitellum. Also, no data exist comparing the size of the capitellum between the left and the right elbow.

METHODS

Eight pairs of elbows and 12 single elbows from fresh-frozen cadavers were obtained for this study. The vertical height and anterior width of the capitellum were measured with digital calipers. Four different measurements were performed at the radial head: longest outer diameter, shortest outer diameter, the long dish diameter, and short dish diameter. The Pearson intrarater intraclass correlation coefficients were obtained for all measurements.

RESULTS

For the paired elbows, the correlations ranged between 0.95 and 0.96 for the capitellar dimensions and 0.77 and 0.98 for the radial head dimensions. The correlations between the long outer diameter of the radial head with the vertical height and the anterior width of the capitellum were 0.8 and 0.9, respectively.

CONCLUSIONS

There is a high correlation between the long outer diameter of the radial head and the vertical height of the capitellum as well its anterior width. There is also a high correlation between the left and the right elbow.

CLINICAL RELEVANCE

These findings are relevant to radiocapitellar arthroplasty and may be useful for radiocapitellar prosthetic design as well as in the preoperative planning of cases in which the radial head and/or the capitellum is destroyed.