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Zhao B, Wang H, Diao S, Xu X, Gao Y, Lu T, Zhou J, Liu Y. Comparison of operatively and nonoperatively treated isolated mason type II radial head fractures: a systematic review and meta-analysis. J Orthop Surg Res 2024; 19:540. [PMID: 39227938 PMCID: PMC11373464 DOI: 10.1186/s13018-024-05039-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Accepted: 08/27/2024] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND Radial head fractures are the most common bony injury of the elbow in adults. The current literature does not agree on whether isolated stable type II radial head fractures should be treated operatively or nonoperatively. This review aims to determine the preferred treatment for Mason type II radial head fractures and compare the outcomes of conservative and surgical treatment. METHODS Our study used PRISMA guidelines and conducted a thorough search of multiple electronic databases, including PubMed, Cochrane, Embase, Web of Science, CNKI, and Wanfang databases, initially identifying 545 relevant publications on surgical and conservative treatment of Mason type II radial head fractures. The final search date for this study is July 7, 2024.Through a comprehensive meta-analysis, we evaluated several outcomes, including functional scores (DASH, OES, and MEPS scores), clinical outcomes (elbow flexion, elbow extension deficit, elbow pronation, and elbow supination), and complication rate (total complications and elbow pain). The mean difference (MD) was compared for continuous outcomes, and the odds ratios (ORs) were compared for categorical outcomes. RESULT A total of 271 patients from 4 studies met the inclusion criteria. Among them, 142 patients received surgical treatment and 129 patients received non-surgical treatment. The study found no statistically significant differences between surgical and non-surgical treatments in DASH, OES, MEPS, elbow flexion, elbow extension impairment, and elbow pain. Compared with surgical treatment, non-surgical treatment was associated with greater elbow pronation (OR = -3.10, 95% CI = [-4.96, -1.25], P = 0.55, I2 = 0%) and a lower complication rate (OR = 5.54, 95% CI = [1.79, 17.14], P = 0.42, I2 = 0%). CONCLUSION Based on the current evidence, conservative management of isolated Mason II radial head fractures yields favorable therapeutic outcomes with a low incidence of complications.
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Affiliation(s)
- Binzhi Zhao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, P.R. China
| | - Hanzhou Wang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, P.R. China
| | - Shuo Diao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, P.R. China
| | - Xiaopei Xu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, P.R. China
| | - Yulin Gao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, P.R. China
| | - Tianchao Lu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, P.R. China
| | - Junlin Zhou
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, P.R. China.
| | - Yang Liu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, P.R. China.
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Azib N, de Klerk HH, Verhaegh R, Sierevelt IN, Verweij LPE, Priester-Vink S, Kooistra B, van den Bekerom MPJ. Type of fixation is not associated with range of motion after operative treatment of proximal radius fractures- a systematic review of 519 patients. JSES Int 2024; 8:1126-1136. [PMID: 39280149 PMCID: PMC11401575 DOI: 10.1016/j.jseint.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2024] Open
Abstract
Background The aims of this study are 1) to assess whether open reduction internal fixation (ORIF) techniques for fractures of the proximal radius are associated with the range of motion (ROM), 2) to determine the incidence of hardware-related complications and removal following plate and screw fixation of the proximal radius, and 3) to evaluate whether the safe-zone definition is described in the literature and its relation to the ROM. Methods A literature search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting ROM in patients undergoing ORIF for radial head or neck fractures were included. Two treatment groups were defined based on ORIF technique: screws only or plates with and without additional screw placement. Results A total of 13 articles were included with 519 patients, of which 271 belonged to the screw group and 248 to the plate group. At final follow-up, the screw group reported a mean supination of 79 (95% CI: 74-83), pronation of 76 (95% CI: 69-84), flexion of 131 (95% CI: 124-138), and loss of extension of 4 (95% CI: 1-7). The plate group reported a mean supination of 72 (95% CI: 65-80), pronation of 697 (95% CI: 60-75), flexion of 126 (95% CI: 118-133), and loss of extension of 7 (95% CI: 1-14). Conclusion Predominantly retrospective studies show that the ROM seems similar for screw and plate osteosynthesis of proximal radius fractures. Complication rates are similar as well. The safe-zone definition is rarely reported.
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Affiliation(s)
- Nadia Azib
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Huub H de Klerk
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands
- Department of Orthopaedic Surgery, University Medical Center Groningen (UMCG) and Groningen University, Groningen, the Netherlands
| | - Remi Verhaegh
- Department of Orthopaedic Surgery, OLVG, Amsterdam, the Netherlands
| | - Inger N Sierevelt
- Xpert Clinics, Orthopedic Department, Amsterdam, the Netherlands
- Spaarnegasthuis Academy, Orthopedic Department, Hoofddorp, the Netherlands
| | - Lukas P E Verweij
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands
- Amsterdam UMC, Location AMC, Department of Orthopedic Surgery and Sports Medicine, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Musculoskeletal Health Program, Amsterdam, the Netherlands
| | - Simone Priester-Vink
- Medical Library, Department of Research and Epidemiology, OLVG, Amsterdam, the Netherlands
| | - Bauke Kooistra
- Department of Orthopedic Surgery, Medische Kliniek Velsen, Velsen-Noord, the Netherlands
| | - Michel P J van den Bekerom
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands
- Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, the Netherlands
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Ibrahim MRK, Semaya AE, Hasan M, Morsy HA. Arthroscopic Percutaneous Fixation of Mason Type 2 Radial Head Fractures. Orthop J Sports Med 2024; 12:23259671241270351. [PMID: 39206051 PMCID: PMC11350551 DOI: 10.1177/23259671241270351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/26/2024] [Indexed: 09/04/2024] Open
Abstract
Background Management of radial head fractures around the elbow with open techniques can predispose to edema, postoperative pain, and adhesions. The resultant limitation in elbow range of motion negatively affects functional outcomes. Rehabilitation is then rendered a challenge in a joint with proneness to stiffness. Hypothesis Arthroscopic percutaneous fixation of Mason type 2 radial head fractures would provide satisfactory radiological and clinical outcomes. Study Design Case series; Level of evidence, 4. Methods A total of 24 patients diagnosed with isolated Mason type 2 radial head fractures at a single institution between February 1, 2021, and December 31, 2021, received arthroscopic percutaneous fixation by headless screws. Functional evaluation included Mayo Elbow Performance Score and postoperative elbow range of motion measurements. Radiological evaluation was performed using elbow radiographs and computed tomography scans. Patients were evaluated for a minimum of 24 months. Results This study included 12 male and 12 female participants with a mean age of 37.29 ± 11.93 years. At the end of the follow-up period (mean, 27.75 months; range, 24-32 months), the mean elbow flexion was 140.17° ± 8.21° and the extension deficit was 4.17° ± 3.81°. The Mayo Elbow Performance Score revealed 21 patients with excellent results and 3 patients with good results. All patients returned to preinjury activities at a mean time of 3.1 months (range, 2-6 months) postoperatively. Union was reached in all patients at a mean time of 7.63 weeks (range, 6-10 weeks). No neurological complications or reoperations were reported at the end of the follow-up period. Conclusion Arthroscopic fixation was demonstrated to be a valid and valuable technique for managing isolated Mason type 2 radial head fractures. It allowed for accurate reduction without the need for soft tissue dissection, resulting in excellent clinical outcomes.
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Affiliation(s)
- Marwa Raafat Kamal Ibrahim
- Department of Orthopedic Surgery and Traumatology, El Hadara University Hospital, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Ahmed Elsayed Semaya
- Department of Orthopedic Surgery and Traumatology, El Hadara University Hospital, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Mohammad Hasan
- Department of Orthopedic Surgery and Traumatology, El Hadara University Hospital, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Hany Adel Morsy
- Department of Orthopedic Surgery and Traumatology, El Hadara University Hospital, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
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France T, Lockwood W, Gu S, Tucker N, Baldini T, Lauder A, Catalano LW. Radiocapitellar and Ulnotrochlear Pressures Increase in a Radial Head Fracture Model: A Cadaveric Biomechanical Analysis. J Bone Joint Surg Am 2024; 106:600-607. [PMID: 38147503 DOI: 10.2106/jbjs.23.00417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
BACKGROUND Changes in intra-articular pressure have not been previously described in relation to the management of radial head fractures. We hypothesized that pressure within the radiocapitellar and ulnotrochlear joints would increase with progressive radial head resection, mimicking a displaced radial head fracture, in a cadaveric model. METHODS Ten cadaveric specimens were tested. Intra-articular pressure sensors were used to measure pressure within the radiocapitellar and ulnotrochlear joints with the forearm in full supination. The elbow was loaded to 100 N in extension, 45° of flexion, and 90° of flexion under the following conditions: (1) intact radial head, (2) 20% radial head resection, (3) 40% radial head resection, and (4) 100% radial head resection. RESULTS The distribution of pressure between the radiocapitellar and ulnotrochlear joints did not change with sequential, partial resection of the radial head (radiocapitellar joint, between 48.92% and 53.79%; ulnotrochlear joint, between 46.21% and 51.08%). After 20% resection, radiocapitellar peak contact pressure (PCP) increased by 22% (from 1,410 to 1,721.5 kPa) and ulnotrochlear PCP increased by 36% (from 1,319 to 1,797.5 kPa). After 40% resection, radiocapitellar PCP increased by 123% (from 1,410 to 3,145 kPa; p = 0.0003) and ulnotrochlear PCP increased by 105% (from 1,319 to 2,702 kPa; p = 0.007). Ulnotrochlear PCP increased by a total of 159% after complete radial head resection (from 1,319 to 3,415.5 kPa; p = 0.003). CONCLUSIONS Pressures in the radiocapitellar and ulnotrochlear joints were equally distributed with an intact radial head and after partial resection. Radiocapitellar and ulnotrochlear pressures increased with increasing radial head resection, significantly exceeding 100% of normal after radial head resection of 40% of the anterolateral diameter. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Thomas France
- Department of Orthopedics, University of Colorado, Aurora, Colorado
| | | | - Songyuan Gu
- University of Colorado School of Medicine, Aurora, Colorado
| | - Nick Tucker
- Department of Orthopedics, University of Colorado, Aurora, Colorado
| | - Todd Baldini
- Department of Orthopedics, University of Colorado, Aurora, Colorado
| | - Alexander Lauder
- University of Colorado School of Medicine, Aurora, Colorado
- Department of Orthopedics, Denver Health Medical Center, Denver, Colorado
| | - Louis W Catalano
- Department of Orthopedics, University of Colorado, Aurora, Colorado
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Ma SB, Lee SK, An YS, Choi HG, Choy WS. Is the 'safe zone' identified in preoperative computed tomography helpful for choosing optimal implant for fixation of radial head fracture? Acta Orthop Belg 2023; 89:709-717. [PMID: 38205765 DOI: 10.52628/89.4.11188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
The purpose of this study is to assess the clinical significance of the radiologic safe zone based on computed tomography and to compare the outcomes of three different implants for fixation of isolated radial head fractures. We retrospectively reviewed 367 patients who underwent internal fixation for isolated radial head fractures. We newly defined two subtypes of Mason type II fractures associated with the radiographic safe zone (IIA, two-part fracture allowing for safe fixation of plate; IIB, two-part fracture not allowing for safe fixation). 170 patients (CCS group, n = 82; HCS group, n = 31; plate group, n = 57) were investigated with no significant differences in demographics. The range of pronation and supination at 1 month postoperatively (P = 0.04 and P = 0.04) and the range of supination at 6 and 12 months postoperatively (P = 0.03 and P = 0.03) were significantly smaller in the plate group. In Mason type IIB fractures, the average MEPS was higher in the CCS and HSC groups than in the plate group (P = 0.01 and P = 0.02). And the average DASH score was lower in the CCS and HCS groups (P < 0.01 and P < 0.01). Evaluation of the radiologic safe zone is potentially helpful in selecting better surgical fixation option. For type III fractures, 2.3-mm cortical screws would be a better option than Acutrak screws. Plates would not be suitable for type IIB radial head fractures.
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Müller M, Mann V, Zapf J, Kirchhoff K, Zyskowski M, Biberthaler P, Kirchhoff C, Wurm M. Functional Postoperative Outcome for 92 Cases of Radial Head Fractures: A PROM-Based Retrospective Study. J Clin Med 2023; 12:5870. [PMID: 37762809 PMCID: PMC10532215 DOI: 10.3390/jcm12185870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Background: Fractures of the radial head are common injuries, whereas, in the case of displaced fractures, surgical treatment using screw or plate osteosynthesis, excision, or replacement of the radial head is required. However, data about patient-related outcomes (PROM) for different types of radial head fractures is limited in the current literature. Therefore, this study was conducted to evaluate the functional outcome after operatively treated radial head fractures and to further correlate these results with the initial modified Mason classification. Methods: In this retrospective study, all suitable patients with surgical treatment of a radial head fracture were identified. Only patients with Mason II-IV fractures were included. All patients completed the Elbow Self-Assessment Score (ESAS) questionnaire. Data on fracture classification, type of surgery, and revision operations (if needed) were assessed. Results: A total of 92 patients suffering from fractures of the radial head (57 Mason II, 35 Mason III-fractures) who were operatively treated at our institution were enrolled. There were 42 (47.7%) female and 50 (54.3%) male patients with an average age of 47.5 ± 14.1 years. Screw osteosynthesis was performed in 67 patients, plate osteosynthesis in 20 patients, and five patients received radial head arthroplasty. The average ESAS score accounted for 89.7 ± 16.7. Mason II fractures showed significantly better functional results with higher ESAS scores (92.3 ± 13.9 vs. 85.4 ± 20.1) as well as significantly lower rates of necessary implant removal (0 vs. 5 (14.3%) than Mason III fractures. Screw osteosynthesis showed significantly better functional ESAS scores, 91.0 ± 16.5, than plate osteosynthesis, with 85.3 ± 17.6 (p = 0.041), but was predominantly used in Mason II fractures. Conclusions: Surgical treatment using screw- and plate osteosynthesis of radial head fractures provides a good overall outcome. The postoperative function is associated with the initial Mason classification as the patients' reported outcome was worse in Mason III fractures compared to Mason type II fractures. In this context, the ESAS score can be considered a useful tool for the assessment of the patient-based functional outcome.
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Affiliation(s)
- Michael Müller
- Department of Trauma Surgery, Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany (J.Z.); (M.Z.); (M.W.)
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Carroll TJ, Dondapati A, Cruse J, Minto J, Hammert WC, Mahmood B. Non-operative Treatment of Mason Type I Radial Head Fractures: A Comparative Analysis Using Patient-Reported Outcomes Measurement Information System (PROMIS). Cureus 2023; 15:e42056. [PMID: 37602006 PMCID: PMC10433034 DOI: 10.7759/cureus.42056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/22/2023] Open
Abstract
OBJECTIVES The purpose of this study is to compare the outcomes of Mason type I radial head fractures. This information will help to provide physicians with a critical decision-making tool when considering non-operative intervention and evaluate Patient-Reported Outcomes Measurement Information System (PROMIS) as a potentially valuable measure to track outcomes. METHODS We retrospectively identified 527 patients undergoing non-operative intervention. Demographic information, physical exam measurements, patient acceptable symptom state (PASS), and PROMIS Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) scores were analyzed over 12 months. RESULTS At the initial outpatient post-injury visit (within one week of injury), the average PROMIS PF, UE, PI, and Depression were 42.04 (SD: 6.3), 35.31 (SD: 7.3), 59.18 (SD: 9.2), and 48.68 (SD: 6.8), respectively. The average change in PROMIS PF, UE, PI, and Depression scores from the time of injury to six weeks were -0.23 (p=0.7), 1.43 (p=0.03), -2.1 (p=0.01), and -0.99 (p=0.1). The average change in PROMIS PF, UE, PI, and Depression scores from the time of injury to six months was -0.56 (p=0.56), 1.84 (p<0.001), -1.84 (p<0.001), and -0.13 (p=0.68). Among patients initially reporting "not acceptable" on PASS and reporting "acceptable" at the six-month visit, the average PROMIS PF, UE, PI, and Depression scores were 42.14, 38.91, 56.91, and 47.51 respectively. This represents an average difference of 1.11 (p=0.07), 2.82 (p<0.01), -1.19 (p=0.04), and -1.7 (p=0.01) respectively. CONCLUSION PROMIS UE and PI significantly improved among Mason I radial head fractures treated non-operatively at both six-week and six-month follow-up points but did not meet the mean clinically important difference (MCID) PROMIS PF did not significantly differ between the time of injury, six-week or six-month follow-up points. Only PROMIS UE correlated with PASS at six-week and six-month follow-up. Among patients who improved from negative to positive responses on PASS, PROMIS UE, and PI significantly improved.
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Affiliation(s)
| | - Akhil Dondapati
- Orthopaedic Surgery, University of Rochester, Rochester, USA
| | - Jordan Cruse
- Orthopaedic Surgery, University of Rochester, Rochester, USA
| | - Jonathan Minto
- Orthopaedic Surgery, University of Rochester, Rochester, USA
| | | | - Bilal Mahmood
- Orthopaedic Surgery, University of Rochester, Rochester, USA
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Davey MS, Davey MG, Hurley ET, Galbraith JG, Molony D, Mullett H, Pauzenberger L. Long-term outcomes of radial head arthroplasty for radial head fractures-a systematic review at minimum 8-year follow-up. J Shoulder Elbow Surg 2021; 30:2438-2444. [PMID: 33812024 DOI: 10.1016/j.jse.2021.03.142] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to systematically review the literature to evaluate the functional outcomes, radiologic outcomes, and revision rates following radial head arthroplasty (RHA) at a minimum of 8 years follow-up. METHODS Two independent reviewers performed a literature search using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using PubMed, Embase, and Web of Science databases. Only studies reporting on outcomes of RHA with a minimum of mean 8 years' follow-up were considered for inclusion. RESULTS Our search found 10 studies including 432 elbows (51% males), with average age of 50 years (15-93) and mean follow-up of 117 months (98-145) met our inclusion criteria. At final follow-up, the mean Mayo Elbow Performance Score and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score were 83 (45-100) and 17 (0-63) respectively, and 86% of patients reported having no or minimal pain. The overall dislocation, subluxation, ulnar neuritis, and infection rates were 2%, 4%, 3%, and 3%, respectively. The rates of radiologic loosening, radiolucency, degenerative change, and heterotopic ossification were 9%, 46%, 27%, and 38%, respectively. The overall surgical revision rates were 20%, with 3%, 15%, and 5% requiring RHA implant revision, removal of metal or implants, and arthrolysis, respectively. CONCLUSION Our systematic review established that RHA results in satisfactory clinical outcomes and modest complication and revision rates at long-term follow-up, despite high levels of radiologic degenerative changes over the same period.
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Affiliation(s)
- Martin S Davey
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland; Department of Trauma and Orthopaedics, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Trauma and Orthopaedics, Galway University Hospitals, Galway, Ireland.
| | - Matthew G Davey
- Department of Trauma and Orthopaedics, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Trauma and Orthopaedics, Galway University Hospitals, Galway, Ireland
| | - Eoghan T Hurley
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland; Department of Trauma and Orthopaedics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John G Galbraith
- Department of Trauma and Orthopaedics, Galway University Hospitals, Galway, Ireland
| | - Diarmuid Molony
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland
| | - Hannan Mullett
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland
| | - Leo Pauzenberger
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland
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