Factors influencing the mid-term radiological and functional outcomes of 41 post-fracture bipolar radial head arthroplasty cases at a mean follow-up of 87 months

Uncementing the status quo: systematic review of a loose-fit, polished stem radial head prosthesis shows stable clinical results in complex elbow injuries with a concomitant radial head fracture

INTRODUCTION

Selecting the optimal radial head prosthesis to treat radial head fractures, especially in the context of complex elbow injuries like terrible triad, Monteggia, and Essex Lopresti, can be challenging, as there is currently no consensus in the field that favors a particular design. This study investigated the safety and performance of a Polished Stem Radial Head Prosthesis (PS RHP) compared to other modern RHP designs.

MATERIALS AND METHODS

A systematic review was conducted according to PRISMA guidelines to capture data on a Polished Stem Radial Head Prosthesis (PS RHP) and other Radial Head Prostheses (RHPs). Functional scores, range of motion, complications, and revisions were extracted from published literature and analyzed in parallel with the percentage of complex injuries. Comparison of functional outcomes between groups were based on minimum clinically important differences (MCIDs).

RESULTS

There were 16 articles reporting on 711 cases of the PS RHP and 23 articles reporting on 605 cases of other RHPs included in the systematic literature review. Functional scores and range of motion were similar amongst the groups. The PS RHP design achieved a comparable revision rate as other RHPs despite a higher number of terrible triad injuries. Notably, the PS RHP group showed a significantly lower rate of instability (1.0%) than other RHPs (3.4%) (p < 0.05). Other complication rates were similar amongst the two groups.

CONCLUSIONS

The PS RHP group had higher rates of terrible triads at baseline compared to the other RHPs group. Regardless of greater injury complexity, the clinical outcomes of the PS RHP group were favorable and resulted in a significantly lower rate of postoperative instability as compared to other RHPs.

Radial head arthroplasty diameter impact on elbow kinematics evaluated by dynamic radiostereometric analysis

Purpose

Radial head arthroplasty (RHA) reestablishes elbow stability after complex radial head fracture, but complication rates are high, possibly due to inappropriate implant sizing. Knowledge of impact of radial head implant diameter on elbow kinematics is limited and warranted. This study evaluated elbow kinematics of different radial head implant diameters after RHA using dynamic radiostereometric analysis (dRSA).

Methods

Eight human donor arms were examined with dRSA during elbow flexion with the forearm in unloaded neutral position, and in supinated- and pronated position without and with 10N either varus or valgus load, respectively. Elbow kinematics were examined before and after RHA with head diameters of anatomical size, -2 mm (undersized), and +2 mm (oversized). The ligaments were kept intact by use of step-cut humerus osteotomy for repeated RHA exchange. Bone models were obtained from CT, and by AutoRSA software bone models were matched with dRSA recordings. The elbow kinematics were described using anatomical coordinate systems.

Results

Compared to the native radial head during elbow flexion, the anatomical sized RHA shifted 2.0 mm in ulnar direction during unloaded pronated forearm position. The undersized RHA shifted 1.5 mm in posterior direction and 2.1 mm in ulnar direction during unloaded pronated forearm position and increased the varus angle by 2.4° during supinated loaded forearm position. The oversized RHA shifted 1.6 mm in radial direction during loaded supinated forearm position.

Conclusions

The anatomically sized RHA should be preferred as it maintained native elbow kinematics the best. The kinematic changes with oversized and undersized RHA diameters were small, suggesting forgiveness for the RHA diameter size.

Level of Evidence

Level III.

Head-to-neck screw fixation and radial head arthroplasty result in similar postoperative outcomes for low-comminuted radial head fractures with neck involvement

Background

Fixation of radial head fractures with neck involvement presents challenges. It remains unclear whether the outcomes of head-to-neck screw fixation are similar to those of arthroplasty in this scenario. We conducted a retrospective cohort study to evaluate the clinical outcomes of these two methods for treating such fractures.

Methods

Demographic data, fracture type, number of fragments, and concomitant injuries were recorded. Range of motion, Visual Analogue Scale for pain, Mayo Elbow Performance Score, and Quick-Disabilities of the Arm, Shoulder, and Hand at three-year follow-up, complications, and reintervention were compared.

Results

A total of 14 patients underwent fixation with head-to-neck screws, and 15 an arthroplasty. Baseline characteristics between groups were similar (P > .05). Satisfactory range of motion (arc > 100°) was achieved in nine patients (64%) in the fixation group, and eight patients (53%) in the arthroplasty group (P = .55). The mean Visual Analogue Scale, Mayo Elbow Performance Score, and Quick-Disabilities of the Arm, Shoulder, and Hand were 1.2 ± 1.2, 91.7 ± 10.7, and 9.1 ± 1, respectively, (P = .651, P = .651, and P = .155). Three patients (21%) in the fixation group underwent a reintervention and three (20%) in the arthroplasty group (P = .639).

Discussion

Head-to-neck screw fixation and radial head arthroplasty result in similar postoperative outcomes for low-comminuted radial head fractures with neck involvement.

Midterm outcomes of a short-cemented bipolar radial head arthroplasty, in a cohort of 56 cases with minimum 2-years follow-up

BACKGROUND

Radial head prostheses are used in comminuted radial head fractures for elbow stabilisation when reduction and internal fixation is not possible. Several implant designs exist, but no large series exist about a short-cemented and bipolar implant.

HYPOTHESIS

The hypothesis was that this prosthesis design shows good clinical, functional, and radiological results, with acceptable rate of complications.

STUDY DESIGN

This retrospective study included the prostheses with bipolar design and short-cemented stem (Evolutive™), with a minimum 2-years follow-up.

MATERIALS AND METHODS

All prosthesis implanted in our Traumatology Center were included, with minimum 2-years follow-up. The evaluation consisted of a clinical and functional evaluation, associated with an independent radiographic assessment. All complications were listed, as long as rate and reasons for implant removal.

RESULTS

Fifty-six implants were studied with a mean follow-up of 64.9months (24 to 119). Fifty-three cases were acute injuries with 16% isolated radial head fractures and 76% complex elbow injury such as ulno-humeral, radio-ulnar or longitudinal forearm instability. Fifty (89%) implants were still in place at last follow-up. The main reason for implant removal was during arthrolysis procedure. Ranges of motion were: 126° in flexion, 9° of extension loss, 76° of pronation and 79° of supination. Mean Mayo Elbow Performance Index was 84.1 with 72% of excellent or good results, and the median quick-DASH was rated 18.2. Radiographic evaluation found 12% significant ulno-humeral arthtitis, 64% capitellar osteopenia and 12% loosening. We recorded 5% of implant-related complications.

DISCUSSION

The short-cemented stem bipolar radial head prosthesis presents clinical and functional results similar to other radial head prosthesis with low incidence of elbow arthritis, when treating both isolated radial head fracture or complexes elbow injury. This implant should therefore be valid for treating comminuted radial head fractures in all types of traumatological injuries.

LEVEL OF EVIDENCE

IV; Retrospective cohort study.

Open reduction and internal fixation of modified Mason type III/IV radial head fractures with more than three fragments: an analysis of the clinical outcome and reoperation rate

PURPOSE

It is generally accepted that a radial head fracture (RHF) with more than three parts is not suitable for repair; therefore, most authors suggest straightforward radial head arthroplasty (RHA). With up to 20% risk for reoperation after RHA, improvement in reduction and fixation techniques may represent a valuable alternative before further extending the indications for arthroplasty. To determine the functional results and radiological failure rate after osteosynthesis of multi-fragmentary RHF with more than three articular fragments. We specifically determined (1) the one-year Broberg and Morrey functional elbow score, (2) duration of fracture healing, (3) complication rate, and (4) number of patients converted to RHA.

METHODS

This study is a retrospective single-center case series. All patients who underwent primary osteosynthesis for RHF between 2012 and 2019 were included. Nine patients with an average age of 52 years had an average clinical and/or radiological follow-up of 49 months.

RESULTS

The preoperative imaging identified nine fractures with four fragments. Three patients underwent osteosynthesis with plates and screws, whereas six patients underwent osteosynthesis with only screws. The mean Broberg and Morrey score was 95 points. Overall, eight of the nine patients had satisfactory results. All patients retained their radial heads and showed radiological fracture healing. Only two patients presented with low-grade complications requiring no further surgery.

CONCLUSION

Our study showed that osteosynthesis of RHF with up to four fragments can achieve good functional results with a low complication rate and seems to be a valid alternative to RHA.

After failed radial head arthroplasty, what are the options? Risk factors and results of revisions in a multicenter study

Introduction

Few multicenter studies have analyzed the outcome of revision surgery of radial head arthroplasties (RHA) in the medium term follow up. The objective is twofold: to determine the factors associated with revision of RHAs and to analyze the results of revision with 2 surgical techniques: isolated removal of the RHA or revision with a new RHA (R-RHA).

Hypothesis

There are associated factors of RHA revision and RHA revision results in satisfactory clinical and functional outcomes.

Methods

Twenty-eight patients were included in this multicenter retrospective study, with all surgical indications for initial RHA being traumatic/post-traumatic. The mean age was 47 ± 13 years with a mean follow-up of 70 ± 48 months. This series included two groups: the isolated RHA removal group (n = 17) and the revision RHA with new radial head prosthesis (R-RHA) group (n = 11). Evaluation was clinical and radiological with univariate and multivariate analysis.

Results

Two factors associated with RHA revision were identified: a pre-existing capitellar lesion (p = 0.047) and a RHA placed for a secondary indication (<0.001). Revision for all 28 patients resulted in improved pain (pre-op Visual Analog Scale 4.7 ± 3 vs. post-op 1.57 ± 2.2, p < 0.001), mobilities (pre-op flexion 118 ± 20 vs. post-op 130 ± 13, p = 0.03; pre-op extension -30 ± 21 vs post-op -20 ± 15, p = 0.025; pre-op pronation 59 ± 12 vs post-op 72 ± 17, p = 0.04; pre-op supination 48 ± 2 vs post-op 65 ± 22, p = 0.027) and functional scores. Mobility and pain control were, for stable elbows, satisfactory in the isolated removal group. When the initial or revision indication was instability, the DASH (Disabilities of the Arm, Shoulder and Hand = 10 ± 5) and MEPS (Mayo Elbow Performance score = 85 ± 16) scores were satisfactory in the R-RHA group.

Discussion

In the case of a radial head fracture, RHA is a satisfactory first-line solution without pre-existing capitellar injury, its results being much weaker in the case of ORIF failure and fracture sequelae. In case of RHA revision, isolated removal or R-RHA adapted according to the pre-operative radio-clinical exam.

Level of evidence

IV.

A systematic review and meta-analysis on different stem fixation methods of radial head prostheses during long-term follow-up

Background: Radial head arthroplasty (RHA) is typically performed for non-reconstructible radial head fractures with or without valgus stability. The fixation methods can be divided into cemented rigid fixation, such as screw fixation, and uncemented micromovement fixation, including smooth stem, press-fit, expanded device, in-growth stem, and grit-blasted stem fixations. Different fixation methods may impact long-term clinical outcomes and cause complications. This study aimed to compare the long-term follow-up outcomes of cemented and uncemented radial head prostheses. Methods: A computerized literature search was performed in the PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science databases for studies on radial head prostheses, replacement, and arthroplasty published from inception to April 2022. The prostheses fixation method was divided into cemented and uncemented fixation groups. The outcomes of interest included the participant characteristics, prostheses types, clinical outcomes, reoperation rates, and complication rates during long-term follow-up. Results: A total of 57 studies involving 2050 patients who underwent RHA were included in our analysis. Cemented fixation was used in 23 of these studies, uncemented fixation in 35 studies, and both cemented and uncemented fixations in one study. Both fixation groups showed significantly improved clinical outcomes after treatment. In particular, both the reoperation and complication rates were lower in the uncemented fixation group (12% and 22%, respectively) than that in the cemented fixation group (20% and 29%, respectively). Among the studies, uncemented monopolar fixation had the lowest reoperation rate (14%), while cemented monopolar fixation had the highest reoperation rate (36%). Regarding complication rates, uncemented bipolar fixation yielded the lowest rate (12%), while cemented bipolar fixation yielded the highest rate (34%). The range of motion and clinical outcome scores were good in both groups. Conclusion: Uncemented radial head prostheses had lower reoperation and complication rates than cemented prostheses. In particular, uncemented monopolar prostheses may yield the lowest reoperation rate, while uncemented bipolar prostheses may yield the lowest overall complication rate.

[Radial head prosthesis for acute fractures]

Non-reconstructible radial head fractures with concomitant injuries and resultant instability of the elbow are often treated by implantation of a radial head prosthesis. Various prosthetic designs and implantation techniques are available. Several pitfalls have to be respected during implantation. This article provides tips and tricks for successful implantation and aftercare and gives an overview of long-term outcomes and revision rates.

Radial head arthroplasty vs. open reduction and internal fixation for the treatment of terrible triad injury of the elbow: A systematic review and meta‑analysis update

Terrible triad injury of the elbow (TTIE) is a severe high-energy injury to the elbow, mainly including elbow dislocation, coronoid fracture and radial head fracture. It is difficult to maintain the stability of the elbow joint using traditional conservative treatment, and there is a high risk of redislocation and various complications. Therefore, surgical treatment is currently advocated, mainly for repairing damaged ligaments and reconstructing bony structures, but there is still controversy about the treatment plan for the radial head. The current meta-analysis was conducted to compare the differences in efficacy of radial head arthroplasty (RHA) and open reduction internal fixation (ORIF) in the treatment of TTIE. Published literature related to the treatment (either ORIF or RHA) of TTIE was searched for in Embase, PubMed, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, ProQuest Dissertations and Theses, Cochrane Library and Chinese Biomedical Literature Database. According to the search strategy, a total of 1,928 related publications were retrieved. The patient must have been diagnosed with TTIE and required surgery on the radial head. The interventions were RHA and ORIF. Non-case-control studies, case reports, review articles, letters, duplicate reports and literature without sufficient relevant data were excluded. The quality of the literature was evaluated according to the Cochrane systematic review methodology and the Jadad scale. After data extraction, meta-analysis was performed using ReviewManager 5.4 software (Cochrane). A total of 15 studies involving 455 patients (189 who underwent RHA and 266 who underwent ORIF) were included. Range of motion (ROM) of the forearm (pronation-supination arc) after surgery in the RHA group [95% CI (0.28, 9.59); P=0.04] was found to be significantly superior to the ORIF group, with a lower incidence of complications [95% CI (0.22, 0.84); P=0.01]. However, there was no statistically significant difference for the Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand Score nor for ROM of the elbow (flexion-extension arc). Overall, compared with the ORIF group, the RHA group had better forearm rotational ROM and fewer complications after surgery. Therefore, RHA was found to be superior to ORIF in the treatment of TTIE.