Resection of the radial head: an alternative to use of a prosthesis?

The minimum follow-up required for radial head arthroplasty: a meta-analysis

AIMS

The primary aim of this study was to define the standard minimum follow-up required to produce a reliable estimate of the rate of re-operation after radial head arthroplasty (RHA). The secondary objective was to define the leading reasons for re-operation.

MATERIALS AND METHODS

Four electronic databases, between January 2000 and March 2017 were searched. Articles reporting reasons for re-operation (Group I) and results (Group II) after RHA were included. In Group I, a meta-analysis was performed to obtain the standard minimum follow-up, the mean time to re-operation and the reason for failure. In Group II, the minimum follow-up for each study was compared with the standard minimum follow-up.

RESULTS

A total of 40 studies were analysed: three were Group I and included 80 implants and 37 were Group II and included 1192 implants. In Group I, the mean time to re-operation was 1.37 years (0 to 11.25), the standard minimum follow-up was 3.25 years; painful loosening was the main indication for re-operation. In Group II, 33 Group II articles (89.2%) reported a minimum follow-up of < 3.25 years.

CONCLUSION

The literature does not provide a reliable estimate of the rate of re-operation after RHA. The reproducibility of results would be improved by using a minimum follow-up of three years combined with a consensus of the definition of the reasons for failure after RHA. Cite this article: Bone Joint J 2017;99-B:1561-70.

Surgical management of the elderly elbow

The elbow has a major role in helping with the positioning of the hand in space. Any pathology of the joint can result in pain, loss of function and difficulties with activities of daily living. With an increasingly elderly population the degenerative conditions affecting the elbow are becoming more prevalent. Besides traumatic injury, the more commonly encountered problems are osteoarthritis, inflammatory arthritis, nerve compression and stiffness. An awareness of these conditions is important for those who provide care to this patient group. Whilst many of these conditions can be managed conservatively in primary care, some patients are referred to secondary care and elect for surgical treatments. This review considers the surgical treatments for the common elbow pathologies in the elderly population, including the potential complications associated with such treatments.

Comparison of crossed screw versus plate fixation for radial neck fractures

BACKGROUND

Fixation of radial neck fractures can be achieved with a plate and screw construct or, in absence of comminution, with two obliquely-oriented screws. This study investigated the mechanical properties, specifically the stiffness and load to failure, of these two fixation strategies in a cadaver model.

METHODS

Ten matched-pair radii were removed from fresh cadaver arms. A transverse osteotomy was created at the neck of each radius. Right-sided radii were fixed with two oblique headless compression screws; left-sided radii were fixed with a radial neck plate. The distal aspect of each radius was potted in urethane casting resin. The radial head was loaded in shear in 4 different planes (medial to lateral, lateral to medial, posterior to anterior, and anterior to posterior) using an Instron machine. Stiffness and load to failure were recorded.

FINDINGS

The stiffness of both constructs was similar in all planes except for loading from medial to lateral where the screw construct was 1.8 times stiffer. Average ultimate failure occurred at 229N for the screws and 206N for the plate. Failure strength was not statistically different. However, mode of failure differed for both fixation constructs, the plate failed in bending while the screws failed by pullout and fracture.

INTERPRETATION

The two strategies provide similar strength and stiffness for the fixation of transverse, non-comminuted radial neck fractures. While plate and screw constructs are more appropriate for axially unstable or comminuted fractures, two oblique screws might be preferred for simple transverse neck fractures since this strategy requires less exposure and the implant is buried.

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 arthroplasty with an uncemented modular metallic radial head prosthesis: short- and mid-term results

BACKGROUND

In comminuted radial head fractures, arthroplasty is an alternative treatment to open reduction and internal fixation or radial head excision. The purpose of this study was to evaluate the short- and mid-term results after the implantation of the EVOLVE™ uncemented modular metallic radial head prosthesis.

METHODS

Twenty-five patients with an unreconstructible comminuted radial head fracture were treated with the EVOLVE™ prosthesis. Two groups were formed in order to evaluate short-term (mean 1.6 years, range 1-2.3 years) and mid-term (mean 5.1 years, range 3-7.2 years) results. The short-term group consisted of 10 patients and the mid-term group of 15 patients. Objective physical outcome (ROM, grip strength) and outcome scores (Broberg/Morrey score, DASH) as well as radiological findings (periprosthetic lucency, prosthetic sizing, heterotopic ossification, posttraumatic osteoarthritis) were evaluated.

RESULTS

Significant impairments in ROM and grip strength were observed in the affected arm. Differences in impairment of the affected arm between the two groups were not significant. There were no significant differences in the outcome scores between the two groups, with good results obtained overall. Understuffing was observed in 3 patients. Three patients had severe and 5 had no periprosthetic lucency. The groups barely differed in periprosthetic lucency.

CONCLUSIONS

Radial head arthroplasty with the EVOLVE™ prosthesis gave good results in terms of objective physical outcome and outcome scores at short- and mid-term follow-up. Periprosthetic lucency does not affect the outcome negatively. We assume that periprosthetic lucency does not necessarily imply prosthesis loosening in which revision is required. Radiological findings and the severity of the initial injury do not necessarily correlate with results.

The emerging role of elbow arthroscopy in chronic use injuries and fracture care

Arthroscopy is emerging as an invaluable tool for diagnosing and treating elbow pathology. In addition to the advantages of less scarring, decreased risk of infection, less postoperative pain, and a more thorough visualization of the elbow joint, arthroscopy is particularly well suited to the treatment of athletes trying to minimize rehabilitation and inactivity. Indications for elbow arthroscopy now extend well beyond diagnosis and loose body removal, and include the treatment of impingement, arthritis, contractures, fragment stabilization for osteochondritis dessicans, and treatment of certain fractures. This article reviews the basic principles and techniques of elbow arthroscopy and their application to common sports-related conditions, such as valgus overload syndrome, medial collateral ligament insufficiency, and the various causes of lateral elbow pain. Newer applications of elbow arthroscopy in fracture care are addressed as well.

Documentation of associated injuries occurring with radial head fracture

We believe a better way is needed to accurately describe the spectrum of associated injuries that commonly occur in conjunction with a radial head fracture. A review of our institution's experience with 333 radial head fractures from 1997 to 2002 documented 88 (26%) associated injuries. Based on this clinical experience, our goal was to develop an accurate and comprehensive description of associated injuries. A shorthand suffix method first recognizes the type of radial head fracture with the traditional Mason classification, followed by abbreviations designating the articular injuries, coronoid (c) and olecranon (o), and the ligamentous injuries, lateral collateral ligament (l), medial collateral ligament (m), and distal radioulnar joint (d). The proposed system offers a logical and reproducible (98%) extension of the current Mason fracture classification to document the presence of additional articular and ligamentous injuries. This provides an opportunity to standardize the communication of fracture type with further details of other injuries that ultimately can help with better understanding of treatment outcome based on the precise injury complex.

Radial head prosthesis after fracture of radial head with associated elbow instability

INTRODUCTION

Fractures of the radial head and associated elbow instability can be treated with operation with radial head prosthesis. In this study, we evaluate function 1-7 years after implantation and also function after removal of five prostheses.

MATERIAL AND METHODS

Eighteen patients with radial head fracture and associated elbow instability were evaluated 3.7 years (1-7) after implantation of a radial head prosthesis. Pain at rest and during activity was measured with a visual analogue scale (VAS). Test of stability and neurological examination was done manually as well as measurement of the range of motion, using a goniometer. Activity of daily living (ADL) was estimated using five questions where the answers were graded between 1 and 3. The patients were asked to grade their general satisfaction according to the following scale; very satisfied, satisfied, not satisfied, disappointed. Plain X-rays were taken and 14 patients agreed to have their elbow strength evaluated using the validated BTE work simulator.

RESULTS

Five prostheses had been extracted due to poor range of motion. All these patients improved after extraction. All elbows were stable. No patient with extracted prosthesis had VAS score >2. The mean extension defect for this group was 15 degrees (5-25) compared to the mean extension defect for the 13 patients with the prosthesis still in place 15 degrees (0-40). The highest VAS score for the patients with prosthesis was five but the mean as low as 0.8. In the whole group, 13 patients were pain free. ADL function was good in general. The X-rays of the prostheses, still in place, showed radiolucent lines in 7 of the 13 patients. In the whole group, there was a significant decrease in supination, flexion and extension strength (P<0.01, P<0.01, P<0.05).

DISCUSSION

Radial head prosthesis works as a spacer after fracture of the radial head and associated instability. If range of motion is much restricted post-operatively, the prosthesis can be removed with improved function as result.

Kinematics and stability of the fractured and implant-reconstructed radial head

Controversy exists as to the optimal management of radial head fractures. Biomechanical studies have been conducted to quantify elbow stability for simulated wedge fractures, head excision, and head replacement, with and without the integrity of the collateral ligaments. Our in vitro studies have demonstrated that in the ligamentously intact elbow, kinematics and stability are slightly altered with simulated depressed wedge fractures up to 120 degrees of the radial head, markedly altered with head resection, and improved after radial head replacement. Radial head excision decreases elbow stability in the ligament-deficient elbow, and radial head replacement improves stability similar to that of the native radial head. The ligaments have the most marked influence on stability, particularly when the upper limb is positioned such that valgus and varus gravity loads are applied to the elbow. Whereas the radial head acts as a secondary stabilizer to the collateral ligaments with the arm in these positions, its relative role is greater when the arm is in the dependent position and elbow flexion is simulated, particularly in extension. Further studies are needed to elucidate the complex interaction of the radial head with the capitellum, the ulnohumeral joint, and the ligamentous structures for different activities of daily living.

Management of comminuted radial head fractures with replacement arthroplasty

Radial head arthroplasty is indicated for displaced comminuted radial head fractures that cannot be managed reliably with open reduction and internal fixation and that have an associated elbow dislocation. Replacement also is indicated in patients with comminuted radial head fractures that have or are likely to have a disruption of the medial col-lateral, lateral collateral, or interosseous ligaments. Biomechanical studies have demonstrated that metallic implants restore elbow stability similar to the native radial head. The early and midterm clinical experience with metallic radial head arthroplasty has been encouraging relative to earlier reports with silicone devices. Newer modular designs incorporate improved sizing to better reproduce the anatomy of the proximal radius and are easier to insert intraoperatively.

The effect of radial head excision and arthroplasty on elbow kinematics and stability

BACKGROUND

Radial head fractures are common injuries. Comminuted radial head fractures often are treated with radial head excision with or without radial head arthroplasty. The purpose of the present study was to determine the effect of radial head excision and arthroplasty on the kinematics and stability of elbows with intact and disrupted ligaments. We hypothesized that elbow kinematics and stability would be (1) altered after radial head excision in elbows with intact and disrupted ligaments, (2) restored after radial head arthroplasty in elbows with intact ligaments, and (3) partially restored after radial head arthroplasty in elbows with disrupted ligaments.

METHODS

Eight cadaveric upper extremities were studied in an in vitro elbow simulator that employed computer-controlled actuators to govern tendon-loading. Testing was performed in stable, medial collateral ligament-deficient, and lateral collateral ligament-deficient elbows with the radial head intact, with the radial head excised, and after radial head arthroplasty. Valgus angulation and rotational kinematics were determined during passive and simulated active motion with the arm dependent. Maximum varus-valgus laxity was measured with the arm in a gravity-loaded position.

RESULTS

In specimens with intact ligaments, elbow kinematics were altered and varus-valgus laxity was increased after radial head excision and both were corrected after radial head arthroplasty. In specimens with disrupted ligaments, elbow kinematics were altered after radial head excision and were similar to those observed in specimens with a native radial head after radial head arthroplasty. Varus-valgus laxity was increased after ligament disruption and was further increased after radial head excision. Varus-valgus laxity was corrected after radial head arthroplasty and ligament repair; however, it was not corrected after radial head arthroplasty without ligament repair.

CONCLUSIONS

Radial head excision causes altered elbow kinematics and increased laxity. The kinematics and laxity of stable elbows after radial head arthroplasty are similar to those of elbows with a native radial head. However, radial head arthroplasty alone may be insufficient for the treatment of complex fractures that are associated with damage to the collateral ligaments as arthroplasty alone does not restore stability to elbows with ligament injuries.

Arthroscopic excision of the radial head: Clinical outcome in 12 patients with post-traumatic arthritis after fracture of the radial head or rheumatoid arthritis

PURPOSE

We performed arthroscopic radial head excision in a series of patients with either post-traumatic arthritis after a radial head fracture or rheumatoid arthritis of the elbow as an expanded indication for elbow arthroscopy. The purpose of the study was to critically examine the results of arthroscopic chondroplasty of the radial head to determine the safety and effectiveness of the procedure.

TYPE OF STUDY

Outcome study and retrospective analysis.

METHODS

From 1990 to 1997, arthroscopic radial head resection was performed in 12 patients with either post-traumatic arthritis (n = 10, Mason type II or III) or with rheumatoid arthritis (n = 2). Functional outcome and radiographs were analyzed after a mean follow-up period of 39 months (range, 12 to 97 months). Elbow arthroscopy was performed using a standardized technique. The anterior three quarters of the radial head and 2 to 3 mm of the radial neck were resected with the abrader in the anterolateral portal and the arthroscope in the proximal medial portal. For resection of the posterior portion of the radial head, the abrader may be transferred to the mediolateral portal. This permits resection of the remnants of the radial head posteriorly and also at the proximal radioulnar joint.

RESULTS

Preoperatively, patients lacked 23 degrees (range, 5 degrees to 40 degrees ) of extension of the elbow on average. Mean flexion was 111 degrees (range, 60 degrees to 145 degrees ). Patients had unrestricted pronation (limitation of 5 degrees in 2 patients). Two patients had a lack of supination of 15 degrees and 30 degrees. Mean follow up was 39 months (range, 12 to 97 months). Postoperatively, patients lacked 9 degrees (range, 0 degrees to 20 degrees ) of extension of the elbow on average. Mean flexion was 136 degrees (range, 90 degrees to 150 degrees ). No patient had subjective or objective evidence of instability of the elbow. All patients except one reported significant improvement in pain relief and complete relief of mechanical symptoms.

CONCLUSIONS

This technically demanding surgical procedure should be reserved for situations of persistent, restricted range of motion and chronic pain. Arthroscopic radial head resection combined with arthroscopic synovectomy relieves elbow stiffness. The surgeon is able to deal with the intrinsic joint pathology, as well as with accompanying symptoms such as synovitis, capsular contracture, or loose bodies.

Arthroscopic resection of the radial head

The authors describe arthroscopic radial head resection in patients with post-traumatic arthritis after fractures of the radial head or in patients with rheumatoid arthritis of the elbow joint, as an expanded indication for elbow arthroscopy. Arthroscopic radial head resection allows the surgeon to deal with the intrinsic joint pathology, as well as with accompanying symptoms such as synovitis, capsular contracture, or loose bodies. The portals used are the proximal medial, anterolateral, and the midlateral portal. The anterior three quarters of the radial head and 2 to 3 mm of the radial neck are resected with the stone-cutting abrader in the anterolateral portal and the arthroscope in the proximal medial portal. For resection of the posterior portion of the radial head, the abrader may be transferred to the midlateral portal. This permits resection of the remnants of the radial head posteriorly and also at the proximal radioulnar joint. Arthroscopic treatment allows the patient to begin and maintain an aggressive postoperative physical therapy program immediately after surgery, thus decreasing the risk of anterior scarring and reoccurring contracture of the capsule of the elbow joint.