Radial head, radiocapitellar and total elbow arthroplasties: a review of recent literature

Antibiotic-loaded spacer arthroplasty in a terrible triad injury with unreconstructable radial head fracture: a case report

BACKGROUND

Radial head arthroplasty is a viable option in cases with terrible triad injuries of elbow, wherein the radial head sustains significant comminution that precludes reconstruction. Nevertheless, this alternative is not recommended for individuals with poor elbow skin conditions, accompanied neuropsychiatric disorders, or low patient compliance. This case report presents a patient with bilateral terrible triad injury, along with the aforementioned conditions. The report outlines the treatment challenges of such a case and proposes potential solutions.

CASE PRESENTATION

A 37-year-old Persian male patient presenting with a bilateral terrible triad fracture-dislocation and a history of psychoactive substance abuse, was admitted to our emergency department. The patient underwent radial head replacement using a cement spacer containing antibiotics, due to the comminuted radial head in the presence of a contaminated wound on the left elbow. The fracture of the right side was successfully fixed. Subsequent to discharge, the patient did not attend any follow-up appointments. After a period of 6 months, he was admitted to the psychiatric ward and orthopedic consultation was requested to evaluate the patient.

CONCLUSION

In acute terrible triad injuries with unreconstructable radial head fractures where arthroplasty with metallic prostheses may not be suitable due to contaminated wounds, unstable psychiatric condition, and low patient cooperation, temporary orthopedic cement spacers can maintain elbow biomechanics, stability, and sterility.

Early aseptic loosening of a press-fit radial head prosthesis - A case series of 6 patients

OBJECTIVE

Radial head arthroplasty (RHA) is the principal treatment option for comminuted radial head (RH) fractures. Here, we present six cases of failed RHA using a modular monopolar press-fit RHA that was subsequently withdrawn from the market because it was associated with a high incidence of loosening.

METHODS

We retrospectively collected data from six patients who had received Radial Head Prothesis System^TM at our centre between July 2015 and June 2016. The average follow-up was 40 months.

RESULTS

Aseptic loosening of the stem affected five (83%) of the six RHA. Four of these were symptomatic and RHA removal was performed. For these patients, the pain subsided and their elbow range of motion (ROM) improved.

CONCLUSION

While the ideal design for an RHA is still debatable, RHA is an efficient treatment option that restores elbow stability and function after a comminuted RH fracture. Importantly, removal of the prosthesis is an effective remedy following RHA associated elbow pain and decreased ROM.

[Radial head arthropolasty in unreconstructable comminuted fractures of the radial head: Long-term results and factors influencing the outcome]

BACKGROUND

Radial head arthroplasty is recognized as the gold standard in the treatment of patients with unreconstructable radial head fractures.

OBJECTIVE

The aim of this retrospective study was to investigate the long-term results after prosthetic replacement of the radial head and in a subgroup analysis to identify factors which influence the outcome.

MATERIAL AND METHODS

A total of 48 patients with unreconstructable fractures of the radial head and neck were treated by cementless radial head arthroplasty between 05/2008 and 10/2018 (30 bipolar prosthesis type rHead Recon, 18 monopolar prosthesis type MoPyc). After a mean follow-up of 4.6 years 39 patients were assessed clinically and radiologically.

RESULTS

The median MEP score was 95 points. Compared to the uninjured side the median range of motion was reduced by 10° for extension/flexion as well as for pronation/supination. In 36 of 39 cases an osseous integration of the prosthesis could be documented. One prosthesis had to be removed after 23 months because of painful loosening. Overlengthening was present in 11 cases (28%), 25 patients (64%) had subcollar bone resorption with a stable osteointegrated stem. Nonbridging heterotopic ossification was observed in 15 patients (38%), 16 patients (41%) showed posttraumatic arthrosis. Patients with sustained elbow dislocation had a significantly worse function in the MEP score and tended to develop an arthrosis more frequently. Ulnohumeral joint degeneration was significantly increased when overlengthening was present.

CONCLUSION

Radial head arthroplasty is an effective treatment option for unreconstructable fractures of the radial head and can provide good to excellent mid-term to long-term results. Sustained elbow dislocation as well as overlengthening of the prosthesis had a negative impact on the clinical outcome.

Impact of radiocapitellar interposition arthroplasty on ulnohumeral joint biomechanics

BACKGROUND

Radial head excision (RHE) has been shown to increase contact pressures within the ulnohumeral joint. Radiocapitellar interposition arthroplasty (RCIA) with the use of a soft tissue graft is an alternative for the treatment of isolated radiocapitellar arthritis or with failure of radial head replacement. We investigated contact pressures and contact area within the ulnohumeral joint after RHE compared to RCIA with dermal autograft.

METHODS

Six fresh-frozen cadaver elbows were tested on a custom dynamic elbow frame. A pressure sensor was inserted into the intact elbow joint, and mean contact pressure, peak contact pressure, contact area, and force within the ulnohumeral joint were recorded at 0°, 30°, 60°, 90°, and 120° of flexion as a valgus load was applied to the elbow. The radial head was then excised and specimens were retested. Finally, a dermal graft matched to the size of the resected radial head was inserted in the radiocapitellar space and the specimens were tested a third time.

RESULTS

At 90° of flexion, contact pressure within the ulnohumeral joint was significantly lower with RCIA compared with RHE (110.8 kPa vs 216.8 kPa; P = .013). The mean peak contact pressure was also significantly lower with RCIA compared with RHE at 90° (279.4 vs 626.7 kPa; P = .025). No statistically significant differences were seen in mean contact area or force between the 3 testing conditions at any flexion position.

CONCLUSION

RCIA with a dermal graft reduced contact pressures within the ulnohumeral joint compared to RHE at 90° of flexion without a significant change in contact area or contact force.

Radiocapitellar Arthroplasty: Systematic Review

Introduction

Primary elbow osteoarthritis affects approximately 2% of the population, and has been treated with arthroplasty. However, total elbow arthroplasty (TEA) implants currently have severe weight limitations and issues with longevity. In patients with unicompartmental arthritis, unicompartmental arthroplasty may be used instead of TEA. We describe the use of Uni-Elbow Radio-Capitellum and Lateral Resurfacing Elbow for radiocapitellar arthroplasty (RCA) in this article.

Methods

Reviewers independently searched databases for keywords, such as radiocapitellar arthroplasty, RCA, uni-elbow radiocapitellum, UNI-E, and lateral resurfacing elbow, LRE. The measured outcomes of interest were the change in motion arc and patient-reported outcome scores. Studies that were not of appropriate quality determined by the Cochrane risk of bias summary tool and review studies were excluded.

Results

RCA resulted in a postoperative 38.3° ± 28.5° increase in elbow flexion-extension (P < .001), and 35.2° ± 28.6° increase in elbow pronation-supination (P < .001). Mayo Elbow Performance Score was significantly increased by 44.8 ± 12.6. DASH Score saw a significant reduction by 45.0 ± 14.6 points (P < .001), while the American Shoulder and Elbow Surgeons Score increased by 47.0 ± 10.6 points (P < .001). Of the 105 adult patients 16.2% experienced complications such as minor stiffness, ulnar neuropathy, component loosening, or radial head UNI-E stem failure. Reported complications were higher in the UNI-E group than in the LRE group.

Conclusion

RCA has shown promise as an option to treat radiocapitellar arthritis, particularly when excising the radial head causes lateral column instability.

Modified Masquelet Technique Assisting 3D Printed Elbow Prosthesis for Open Elbow Fracture with Severe Bone Defect: A Case Report and Technique Note

BACKGROUND

Internal fixation for severe open articular bone defects is sometimes ineffective or dangerous. In the emergency stage, radical debridement and infection prevention are demanded to provide a good tissue base and the space-occupying effect to provide enough necessary space to avoid soft-tissue contraction for the reconstruction. In addition, the 3D printing technology makes individual limb reconstruction a reality.

CASE PRESENTATION

Here, we present a 31-year-old patient with an open fracture and severe bone defect of his left elbow caused by traffic accident, classified as Gustilo-Anderson IIIB. We adopted aggressive debridement and insertion of polymethyl methacrylate (PMMA) to prevent the infection and temporarily construct the bone defect in the emergency stage. Secondly, the total elbow arthroplasty was performed using a unique three-dimensional (3D) printed prosthesis to reconstruct the elbow joint. During the follow-up, the elbow movement function was satisfactory.

CONCLUSIONS

The modified Masquelet technique assisting 3D printing of personalized elbow joint makes the satisfactory functional reconstruction for open high-energy injuries come true. It could be promoted for the similar surgery of other open joints fractures with severe bone defects.

[Elbow prosthesis after acute fractures : Indications and technique]

Good to very good clinical results can be achieved in older patients with the implantation of a total elbow prosthesis in cases of distal humeral fractures by taking the morphological features of the fractures, the bone quality as well as the individual patient requirements and variables into account. The most commonly used design is the cemented semiconstrained linked total elbow endoprosthesis. The unlinked prosthesis design and hemiarthroplasty require intact or adequately reconstructable musculoligamentous structures or condyles and a preserved or replaced radial head. The recommended weight limit after total elbow prosthesis as well as potential intraoperative and postoperative complications must be considered and discussed with the patients. A secondary total elbow arthroplasty is also possible after primary conservative treatment approaches, e.g., in the case of contraindicated surgery in the fracture situation, persistent pain and functional restrictions. This article provides an overview of the technique and the appropriate indications.

Total Elbow Arthroplasty and Antegrade Posterior Interosseous Flap for Infected Posttraumatic Arthritis with an Active Fistula. A Rationale for Comprehensive Treatment. Case Report

The indication for total elbow arthroplasty (TEA) for primary and posttraumatic elbow arthritis has increased, however, its indication after infection remains elusive. Wound closure about the elbow increases the challenge of treating a previously infected elbow, often necessitating soft tissue coverage with local or regional flaps. We present a 75-year-old male patient with an elbow infection following a failed complex intraarticular fracture open reduction and internal fixation of the distal humerus. Initially, he presented with severe functional impairment and pain, also with an active fistula with serous exudate, whose culture was positive for Cutinebacterium acnes. Septic hardware loosening, and septic nonunion with intraarticular involvement of the left elbow was diagnosed. The patient underwent hardware removal, fistulectomy, serial irrigation and debridement and a pedicled antegrade posterior interosseous artery (PIA) flap on staged surgical treatment. Finally, after ruling out infection persistence, a TEA was performed. We aim to report the outcome of a patient treated with a TEA in the context of a previously infected elbow with soft tissue coverage with an antegrade PIA flap. Comprehensive treatment must be done in an appropriate manner, to obtain an expedited and desirable outcome.

Pyrocarbon unipolar radial head prosthesis: clinical and radiologic outcomes at long-term follow-up

BACKGROUND

Several studies have already reported good short-term results with a pyrocarbon unipolar radial head prosthesis (Pyc-uRHP). The aim was to evaluate the evolution from mid- to long-term clinical and radiographic outcomes of a Pyc-uRHP.

METHODS

This was a retrospective, single-center study. We followed up all the patients who underwent Pyc-uRHP surgery in our original study at 2 years of follow-up (52 patients), reaching a minimum of 7 years of clinical and radiologic follow-up. This study included 26 patients who underwent a clinical examination assessing mobility, the Mayo Elbow Performance Score, and the visual analog scale score and radiologic evaluation with anteroposterior and profile radiographs at a mean follow-up of 110 months (range, 78-162 months). The radiologic study analyzed signs of proximal osteolysis, stem loosening, capitellar wear, and humeroulnar osteoarthritis.

RESULTS

No patients required revision. Eight patients required reoperation: coronoid screw removal in 1 and arthrolysis for stiffness in 7. The mean time to reoperation was 11 months. The mean Mayo Elbow Performance Score at last follow-up was 96 ± 9 (of 100), with a pain score of 42 ± 7 (of 45), mobility score of 19 ± 2 (of 20), stability score of 10 (of 10), and function score of 25 (of 25). Comparison with clinical data from the mid-term delay did not reveal any significant difference. All patients presented with proximal osteolysis around the neck but without progression. No stem loosening was noted. The rates of humeroulnar osteoarthritis (12% at mid-term vs. 80% at last follow-up, P < .0001) and capitellar lesions (34% at mid-term vs. 80% at last follow-up, P = .001) increased significantly.

CONCLUSION

We have shown that a Pyc-uRHP at 9 years' follow-up provided stable and satisfactory clinical results. Osteolysis of the radial neck was always present but it did not evolve, and no stem loosening was noted. Finally, we have shown a clear worsening of radiologic humeroulnar osteoarthritis and capitellar lesions that remained asymptomatic.

Correlations Between Radial Head Diameters and Humeral Articular Dimensions: Bilateral MRI Morphometric Analysis on 39 Healthy Subjects

PURPOSE

Choosing the correct size of head component in radial head arthroplasty is often challenging, particularly in comminuted fractures, deformities, and revision surgery. The main aim of this study was to investigate possible correlations between radial head diameters and the morphometric parameters of the articular distal humerus in order to find mathematical equations that may be used to infer radial head dimensions indirectly.

METHODS

We performed bilateral elbow magnetic resonance imaging on 39 healthy young subjects, comprising 19 women and 20 men, with a mean age of 28 years (range, 21-32 years). The following measurements, which included cartilage thickness, were calculated on the axial plane: maximum (Dmax) and minimum (Dmin) radial head diameters, capitellum width, capitellum to lateral trochlear ridge width (CAP-TROCHridge), humeral articular width (HUMwidth), capitellum radius of curvature, and lateral, medial, and total trochlear width. The anteroposterior diameters of the capitellum, trochlear sulci, and lateral and medial trochlear ridges were measured on the sagittal plane.

RESULTS

CAP-TROCHridge and HUMwidth were found to be the parameters most strongly correlated with the radial head diameters. Four mathematical equations that allowed Dmax and Dmin to be calculated with an average residual error less than 1 mm, were obtained. The intraclass coefficient was greater than 0.95 for all the measurements.

CONCLUSIONS

Radial head diameters can be accurately inferred from 2 humeral dimensions by magnetic resonance imaging. The HUMwidth, which is not influenced by cartilage thickness, may be useful for planning with preoperative imaging because it can also be calculated by computed tomography scan, whereas CAP-TROCHridge, which is influenced by cartilage thickness, might be useful for direct intraoperative measurement.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Radiocapitellar arthroplasty

This article sets out the evidence demonstrating that the clinical need for a prosthetic arthroplasty designed specifically for the radiocapitellar joint has been underestimated. The prevalence of radiocapitellar degenerative change requiring treatment is discussed and the relationship between 'isolated' radiocapitellar joint arthritis and more generalised elbow arthritis is explained. Current literature now supports our view that radiocapitellar joint arthroplasty is not only an effective long-term solution for patients with localised radiocapitellar arthritis but also for those patients with more severe degenerative changes involving the elbow joint irrespective of their cause. We consider that is important to avoid resection of the radial head and therefore that resurfacing implants rather than joint replacement implants are more likely to provide a good longterm outcome for patients with elbow arthritis.

Post-traumatic elbow osteoarthritis after radial head arthroplasty: Prevalence and risk factors

BACKGROUND

One of the treatment options for comminuted radial head fractures is radial head arthroplasty (RHA), especially when the elbow is also dislocated. While the clinical outcomes of RHA have been well documented, the incidence of post-traumatic osteoarthritis after RHA and its risk factors are not well known.

OBJECTIVE

To determine the incidence of post-traumatic elbow osteoarthritis (humeroulnar and humeroradial joints) after RHA and identify its risk factors.

METHODS

All patients who underwent RHA at our hospital between 2008 and 2016 were included retrospectively. The inclusion criteria were primary RHA, recent radial head fracture (isolated or associated with elbow dislocation), minimum 1 year of follow-up, clinical and radiographic examination at final assessment. The exclusion criteria were pre-existing elbow osteoarthritis, RHA revision, multiple fractures of the ipsilateral upper limb or polytrauma. The final assessment consisted of a clinical examination [joint range of motion (ROM) and Mayo Elbow Performance Score (MEPS)] and standard radiographs. The correlation between the incidence and severity of osteoarthritis and various risk factors was determined.

RESULTS

Seventy-three patients were included in the analysis with a mean age of 56 years (21-85). The injuries consisted of 41 terrible triad, 15 isolated radial head fractures, 11 Monteggia fractures and 6 transolecranon fracture-dislocations. The mean follow-up was 3.4 years (1-10.9). At the final assessment, osteoarthritis was visible in the humeroulnar compartment in 56% of cases and in the humeroradial compartment in 72% of cases. There was a statistical correlation between the presence of humeroulnar osteoarthritis at the final assessment and ROM in flexion-extension (p=0.003), MEPS (p<0.001), duration of immobilization (p=0.03) and presence of posterior subluxation on immediate postoperative radiographs (p=0.012). The correlation between humeroradial osteoarthritis at the final assessment and ROM in flexion-extension (p=0.0054), RHA implant position (p<0.01), and unipolar configuration (p=0.027) was statistically significant.

CONCLUSION

In our study, elbow osteoarthritis incidence after RHA was 56% in the humeroulnar joint and 72% in the humeroradial joint. RHA implant placement, posterior subluxation immediately postoperative and the duration of immobilization were significantly corelated with osteoarthritis.

LEVEL OF EVIDENCE

IV; case series without control group.

Midterm outcomes of 146 EVOLVE Proline modular radial head prostheses: a systematic review

INTRODUCTION

The EVOLVE implant (Wright Medical Technology, Arlington, TN, USA) is a modular loose-fitting radial head prosthesis. The primary objective was to synthesize all available literature investigating the midterm clinical outcomes of the EVOLVE implant.

MATERIALS AND METHODS

An electronic literature search in Pubmed/Medline, Scopus, EMBASE, and Cochrane library was performed querying for studies published in 2000-2017. Articles describing clinical and radiographical outcomes as well as reoperation were included. Outcomes of interest included range of motion, Mayo Elbow Performance Score, Disabilities of the Arm Shoulder and Hand, radiographic outcome, and reason for reoperation.

RESULTS

A total of five articles consisting of 146 patients with EVOLVE implants were included. Mean patient age was 57.4 years (range 22-84), and 43.8% were males (n = 64). Mean follow-up was 4.8 years (range 1-14). Mean Mayo Elbow Performance Score and Disabilities of the Arm Shoulder and Hand score were 87.6 (range 30-100) and 18.9 (range 0-82), respectively. Midterm clinical results were good or excellent (Mayo Elbow Performance Score > 74) in 94 patients. Reoperation was observed in 12 patients, with implant revision required in 2 patients. The primary reason for reoperation was persistent stiffness (n = 9).

CONCLUSION

Midterm outcomes of EVOLVE radial head prosthesis are satisfactory, and associated complication rates are low. Loose-fit implant method appears to be a reliable approach to avoid failure of radial head prosthesis by painful loosening.

Does shape and size of the stems affect the stress-shielding around press-fit radial head arthroplasty?

AIMS

It has been hypothesized that proximal radial neck resorption (PRNR) following press-fit radial head arthroplasty (RHA) is due to stress-shielding. We compared two different press-fit stems by means of radiographs to investigate whether the shape and size of the stems are correlated with the degree of PRNR.

METHODS

The radiographs of 52 RHAs were analyzed both at 14 days postoperatively and after two years. A cylindrical stem and a conical stem were implanted in 22 patients (group 1) and 30 patients (group 2), respectively. The PRNR was measured in the four quadrants of the radial neck and the degree of stem filling was calculated by analyzing the ratio between the prosthetic stem diameter (PSD) and the medullary canal diameter (MCD) at the proximal portion of the stem (level A), halfway along the stem length (level B), and distally at the stem tip (level C).

RESULTS

Overall, 50 of the 52 patients displayed PRNR. The mean PRNR observed was 3.9 mm (0 to 7.4). The degree of endomedullary stem filling at levels A, B, and C was 96%, 90%, and 68% in group 1, and 96%, 72%, and 57%, in group 2, with differences being significant at levels B (p < 0.001) and C (p < 0.001). No significant correlations emerged between the severity of PRNR and the three stem/canal ratios either within each group or between the groups.

CONCLUSION

PRNR in press-fit RHA appears to be independent of the shape and size of the stems. Other causes besides stem design should be investigated to explain completely this phenomenon. Cite this article: Bone Joint J 2021;103-B(3):530-535.

Surgical Selection of Unstable Intertrochanteric Fractures: PFNA Combined with or without Cerclage Cable

Due to the instability of unstable intertrochanteric fractures, the selection of a suitable internal fixation has always been a challenge for orthopedic surgeons. This study is aimed at comparing the clinical efficacy of PFNA combined with cerclage cable and without cerclage cable and finally recommend a stable internal fixation method to provide the basis for clinical therapy. From January 2014 to January 2018, we retrospectively analyzed all cases of unstable intertrochanteric fractures who received treatment in the Orthopedics Department of our hospital and finally screened 120 cases, 51 of whom were treated with cerclage cable, 69 without cerclage cable. The follow-up period was one year. HHS, BI, and RUSH scores were given within the specified time. We divided the patients into the PFNA+cable (PFNA combined with cerclage cable) group and the PFNA group. The time of fracture healing and weight-bearing in the PFNA+cable group was shorter than that in the PFNA group. With regard to HHS, BI, and RUSH, the PFNA+cable group was higher than the PFNA group at 1 month, 3 months, 6 months, and 12 months after operation. For HHS rating, the PFNA+cable group has a higher excellent rate than the PFNA group, which was 96.1% and 84.1%, respectively. All the results mentioned above were statistically significant. Compared with the group without cerclage cable, the application of cerclage cable can reduce the incidence of complications. From the comparison between the two groups, it can be seen that the surgical method of PFNA combined with cerclage cable can not only help to improve the stability of fracture reduction, shorten the time of fracture healing and postoperative weight-bearing, and significantly improve patients' self-care ability but also reduce the incidence of postoperative complications. Therefore, we think PFNA combined with cerclage cable is a good choice.

Arthroscopic and open debridement in primary elbow osteoarthritis: a systematic review and meta-analysis

Primary osteoarthritis (OA) of the elbow can cause disabling symptoms of pain, locking, stiffness, and a limitation in the range of motion. There is no consensus regarding the role of open and arthroscopic debridement in the treatment of symptomatic primary elbow OA. The aim of this study is to systematically review the outcome of surgical debridement. A preoperative/postoperative comparison will be made between the two surgical procedures.

All studies reporting on debridement as treatment for primary elbow OA with a minimum of one-year follow-up were included. Outcome parameters were functional results, complications, and performance scores.

Data were extracted from 21 articles. The arthroscopic group consisted of 286 elbows with a weighted mean follow-up of 40 ± 17 months (range, 16–75). The open group consisted of 300 elbows with a weighted mean follow-up of 55 ± 20 months (range, 19–85). Both procedures showed improvement in Mayo Elbow Performance Score (MEPS), range of motion (ROM) flexion-extension, and ROM pronation-supination. Only in ROM flexion was a statistically significant difference in improvement seen between the groups in favour of the open group. The arthroscopic group showed improvement in pain visual analogue scale (VAS) scores. Nothing could be stated about pain VAS scores in the open group due to a lack of data. In the arthroscopic group 18 complications (6%) were described, in the open group 29 complications (12%).

Surgical debridement is an effective treatment for the disabling symptoms of primary elbow OA with an acceptable complication rate.

Cite this article: EFORT Open Rev 2020;5:874-882. DOI: 10.1302/2058-5241.5.190095

Acute radial head replacement with bipolar prostheses: midterm results

In irreparable radial head fractures, especially if primary stabilizers of the elbow are damaged, the prosthetic replacement prevents instability and stiffness. Concerns have arisen over the use of bipolar press-fit prostheses due to the frequent finding of osteolysis and the risk of instability if compared to monopolar implants. Our aim was to assess midterm clinical and radiological outcomes of bipolar implants and the influence of osteolysis on proximal pain. Seventeen patients with irreparable fractures of the radial head, treated in acute with the same prosthetic model (rHEAD recon SBI/Stryker) between January 2015 and December 2018, were enrolled. Clinical assessment was performed using MEPS and DASH scores; a radiographic study was done to identify heterotopic ossifications and periprosthetic osteolysis. Outcomes at the last follow-up, according to MEPS, were excellent in 10 cases, good in 5 and fair in 2; none of the patients had severe pain or instability. In 3 cases, it was necessary to remove the implant, mainly because of early loosening. Radiological findings of osteolysis were detected in 9 cases, but no statistical correlation was found with MEPS and proximal pain. The use of bipolar implants is reliable if an accurate repair of ligament tears is performed and provides a good stability. Nevertheless, the risk of early aseptic loosening in uncemented implants is not negligible, and the follow-up of the patient must be strict. Late osteolysis does not seem to have clinical relevance, but further prospective studies are necessary to clarify this topic.

Reliability of dynamic fluoroscopy for medial elbow stability in the presence of radial head resection

Background

The aim of this study was to examine whether dynamic fluoroscopy is reliable for assessment of medial elbow stability in the presence of radial head resection and different stages of medial collateral ligament (MCL) dissection in a cadaveric elbow model.

Materials and methods

Six intact elbow specimens were measured for joint angulation while applying valgus stress in four examination conditions (Examiner 1, Examiner 2, 1 Nm, 2 Nm) in four different elbow positions (fully pronated or supinated at 0° of elbow extension and 30° of elbow flexion). The elbow specimens were examined for valgus stress in three stages: (1) intact, (2) after radial head resection, and (3) after subsequent dissection of the complete MCL. Anteroposterior radiographs of the elbow were made at each stage to determine joint angulation. Intraclass correlation coefficients (ICCs) were calculated.

Results

In intact elbows, mean joint angulation ranged from 2.2° ± 2.0 (1 Nm) to 5.2° ± 2.3 (Examiner 1). Radial head resection did not increase joint angulation during valgus stress, regardless of joint position and examination condition (Examiner 1: 5.5°; Examiner 2: 5.0°; 1 Nm: 2.6°, 2 Nm: 3.9°). Additional dissection of the MCL led to significantly higher joint angulation during measurements with the standardized torques (1 Nm: 12.4°; 2 Nm: 23.3°). Very good to excellent ICCs for joint angulation between Examiner 1 and Examiner 2 (0.861 to 0.959) were found.

Conclusion

Dynamic fluoroscopy is a reliable diagnostic tool for determining medial elbow stability in the presence of radial head resection and different stages of MCL dissection.

The clinical impact of arthroscopic vs. open osteocapsular débridement for primary osteoarthritis of the elbow: a systematic review

BACKGROUND

Primary elbow osteoarthritis (PEOA) is a debilitating disease that can be difficult to treat. Osteocapsular débridement (OD) has been described through various approaches, including arthroscopic and open approaches, with successful outcomes in treating PEOA. There is insufficient evidence in the literature to date to demonstrate the superiority of any approach. The purpose of this review was to compare the clinical results of arthroscopic vs. open OD for PEOA.

METHODS

The online databases PubMed, Embase (Elsevier), and Scopus (Elsevier) were searched from inception through April 1, 2018, for clinical studies reporting on OD. Studies were stratified based on an arthroscopic vs. open approach. Weighted means were calculated for surgical and patient-reported outcomes.

RESULTS

We included 30 studies, reporting on 871 patients and 887 elbows, with a mean follow-up period of 44.3 ± 25.5 months. Of these studies, 15 (420 elbows) reported on open OD, 14 (456 elbows) reported arthroscopic OD, and 1 reported on a cohort of each approach (open in 5 elbows and arthroscopic in 6). The Mayo Elbow Performance Score improved by 28.6 ± 4.57 in the open group vs. 26.6 ± 7.24 in the arthroscopic group. Flexion improved by 19° ± 6° in the open group and 10° ± 6° in the arthroscopic group. Extension improved by 11° ± 5° in the open group and 11° ± 6° in the arthroscopic group.

CONCLUSIONS

Open OD and arthroscopic OD are effective surgical treatment options for patients with symptomatic PEOA, reliably improving flexion, extension, and functional outcome scores with low complication rates.

Total Elbow Arthroplasty: Clinical Outcomes, Complications, and Revision Surgery

Total elbow arthroplasty is a common surgical procedure used in the management of advanced rheumatoid arthritis, posttraumatic arthritis, osteoarthritis, and unfixable fracture in elderly patients. Total elbow prostheses have evolved over the years and now include the linked, unlinked, and convertible types. However, long-term complications, including infection, aseptic loosening, instability, and periprosthetic fracture, remain a challenge. Here, we introduce each type of implant and evaluate clinical outcomes and complications by reviewing the previous literature.

Joint contact areas after radial head arthroplasty: a comparative study of 3 prostheses

BACKGROUND

Contact stresses of radial head prostheses remain a concern, potentially leading to early capitellar cartilage wear and erosion. In particular, point contact or edge loading could have a detrimental effect. The purpose of this study was to compare 3 different types of radial head prostheses in terms of joint contact areas with each other and with the native situation. The hypothesis was that the joint contact areas would be lower after monopolar arthroplasty.

METHODS

Seven fresh-frozen cadaveric upper limbs were used. Radiocapitellar contact areas of a monopolar design, a straight-neck bipolar design, and an angled-neck bipolar design were compared with each other and with the native joint. After standardized preparation, polysiloxane was injected into the loaded radiocapitellar joint to create a cast from which the joint contact area was measured. Measurements were performed at 3 angles of elbow flexion and in 3 different forearm positions.

RESULTS

In the native elbow, contact areas were highest in supination. Elbow flexion had no significant effect on native and prosthetic joint contact areas. Contact areas were decreased for all types of arthroplasties compared with the native joint (from 11% to 53%). No significant contact area difference was found between the 3 designs. However, bipolar prostheses showed lateral subluxation in neutral forearm rotation, resulting in a significant decrease in the contact areas from pronation to the neutral position.

CONCLUSIONS

All types of radial head prostheses tested showed a significant decrease in radiocapitellar contact area compared with the native joint. Bipolar designs led to subluxation of the radial head, further decreasing radiocapitellar contact.

Primary cemented bipolar radial head prostheses for acute elbow injuries with comminuted radial head fractures: mid-term results of 37 patients

BACKGROUND

Radial head arthroplasty represents a widely accepted treatment for elbow injuries with non-reconstructible radial head fractures. The aim of this retrospective multicenter study was to assess mid-term results of patients with clearly defined elbow injuries including type III fractures of the radial head according to Mason's classification type III after primary arthroplasty using a cemented bipolar design.

MATERIALS AND METHODS

In 45 cases a primary cemented bipolar arthroplasty of the radial head was implanted for elbow injuries combined with an acute Mason type III radial head fracture. In all patients associated fractures were detected with preoperative CT scans and ligamentous injuries were evaluated and both were addressed intraoperatively based on a standardized algorithm. Patients with associated injuries other than coronoid fractures and collateral ligament tears were excluded from this study to obtain a more homogenous sample. Clinical and radiological assessment was performed on thirty-seven patients at an average of 5.6 years postoperatively.

RESULTS

DASH Score, functional rating index of Broberg and Morrey, Mayo Elbow Performance Score, and Mayo Modified Wrist Score confirmed good-to-excellent results in most of the patients. Compared to the unaffected arm range of motion and grip strength were slightly reduced. No elbow instability or loosening of the prosthesis, and minor degenerative changes were detected in a few cases.

CONCLUSION

Primary cemented bipolar arthroplasty for type III fractures according to Mason's classification in an elbow injury pattern only including associated coronoid fractures and/or ligamentous tears resulted in good-to-excellent mid-term results. These results suggest that primary bipolar radial head arthroplasty combined with distinct treatment of all associated injuries provides good functional outcomes concerning range of motion, elbow stability, and strength in this cohort. However, the associated injuries may influence clinical and radiological outcome and need to be detected, classified, and treated carefully.

Radiocapitellar arthroplasty: a consecutive case series with 2 to 6 years' follow-up

BACKGROUND

The aim of this study was to analyze indications, outcomes, and complications in patients treated with radiocapitellar arthroplasty.

METHODS

This prospective analysis of clinical and radiographic results included 16 elbows in 15 patients.

RESULTS

This study included 4 men and 11 women (mean age, 51.9 years; age range, 32-65 years). The mean follow-up period was 3.4 years (range, 2-6 years). The indications were post-traumatic (n = 10) and primary radiohumeral osteoarthritis (n = 6). A mean of 2 surgical procedures (range, 0-4) had been performed before radiocapitellar arthroplasty. The mean Mayo Elbow Performance Score significantly improved from 46 points to 85 points (P < .01). The arc of motion improved from 106° to 117° (P = .27). Radiographic ulnohumeral degeneration progressed in 40% of cases but was not symptomatic in any. Subsequent surgery was required in 5 elbows (31%). Revision of the radial head component was necessary in 4 patients (25%). In 3 patients this was a result of loosening of the stem. The radial component was subsequently removed because of persistent pain in 1. Radiographic loosening not requiring revision was found in 2 patients.

CONCLUSION

The overall Mayo Elbow Performance Score was good to excellent after radiocapitellar arthroplasty. Both the revision and reoperation rates were high, and one should consider this before performing this procedure. Loosening of the radial head component was a problem. An improved fixation technique or an adaptation of the design is needed before this type of surgery can be recommended as a standard procedure.

Does radial head implant fixation affect functional outcomes? A systematic review and meta-analysis

BACKGROUND

Radial head arthroplasty is used in the treatment of nonreconstructible radial head fractures. Although traditional implants have been loosely fixed, smooth stemmed implants functioning more as spacers, modern designs have introduced press-fit, tapered implants that articulate at the capitellum with more rigidly maintained congruity. Cemented implants also use rigid initial fixation. This study was conducted to help determine which fixation method results in better functional outcomes: "fixed" or "unfixed."

METHODS

A systematic review and meta-analysis was used. We identified 63 articles via 3 databases. Ten non-English or articles with insufficient text were excluded, and 17 others did not contain sufficient data or follow-up. The remaining 36 articles were qualitatively and quantitatively reviewed.

RESULTS

We identified 36 populations, with 878 unduplicated patients: 522 fixed and 356 unfixed. Respectively, mean follow-up in months was 46.2 and 37.4. Average Mayo Elbow Performance Scores were 85.9 and 88.2 (P = .08). Average Disabilities of the Arm, Shoulder and Hand scores were 17.1 and 18.7 (P = .47). Average final flexion/extension arcs were 119.1° and 115.8° (P = .08). Revision rates were 7.9% and 3.1%, and complication rates were 25.5% and 13.2%. Relative risks of revision and complications for the fixed cohort were 2.48 (P = .006) and 1.88 (P < 0.0001), respectively.

CONCLUSIONS

Implant fixation type does not appear to affect functional outcomes of radial head arthroplasty. However, rigidly fixing the implant may increase the risks of revision and complications.

Pyrocarbon arthroplasty in acute unreconstructable radial head fractures: mid-term to long term results

BACKGROUND

The aim of this study is to describe the mid-term radiological findings appearing in patients with a pyrocarbon radial head prosthesis, and to correlate them to patient symptoms.

MATERIALS AND METHODS

We review 18 patients who underwent radial head implantation of the MoPyC prosthesis between 2004 and 2015, due to unreconstructible radial head fractures. The clinical outcomes were assessed with Mayo Elbow Performance Score (MEPS). Range of motion, pain, and elbow radiological assessments were recorded. A non-parametric, statistical analysis was carried out to assess the radiological findings with the clinical outcomes.

RESULTS

We have found that after a mean follow-up of 6.5 years (2-11 years), patients have recovered a median flexion arch of 113°, therefore 77% are classed as satisfactory outcomes and the average MEPS score is 89.5. The presence of periprosthetic changes on X-ray is highly frequent-we found radiolucent lines in 38% of cases, radial neck re-absorption in 83%, and arthrosic changes in 78%. However, the differences found when correlating these changes with the clinical results have not been statistically significant (p > 0.05).

CONCLUSIONS

Satisfactory outcomes can be expected midterm when using pyrocarbon prostheses in around 75% of the cases. We consider radial neck re-absorption to be a sign of good stem osteointegration, whereas progressive radiolucencies and loss of the ballooning of the stem legs are signs of bad prognosis in our series.

LEVEL OF EVIDENCE

IV retrospective case series.

Short to midterm outcomes of one hundred and seventy one MoPyC radial head prostheses: meta-analysis

BACKGROUND

The MoPyC implant is an uncemented long-stemmed radial head prosthesis that obtains primary press-fit fixation via controlled expansion of the stem. Current literature regarding MoPyC implants appears promising; however, sample sizes in these studies are small. Our primary objective was to evaluate the short- to midterm clinical outcomes of a large sample of the MoPyC prostheses. The secondary objective was to determine the reasons for failure of the MoPyC devices.

METHODS

Four electronic databases were queried for literature published between January 2000 and March 2017. Articles describing clinical and radiographic outcomes as well as reasons for reoperation were included. A meta-analysis was performed to obtain range of motion, mean Mayo Elbow Performance score (MEPS), radiographic outcome, and reason for failure.

RESULTS

A total of five articles describing 171 patients (82 males) with MoPyC implants were included. Mean patient age and follow-up were 52 years (18-79) and 3.1 years (1-9), respectively. Midterm clinical results were good or excellent (MEPS > 74) in 157 patients. Overall complication rate was low (n = 22), while periprosthetic osteolysis was reported in 78 patients. Nineteen patients returned to the operating room, with implant revision being required in ten patients. The two primary reasons for failure were (intra-)prosthetic dislocation (n = 8) followed by stiffness (n = 7); no painful loosening was described.

CONCLUSION

Short- to midterm outcomes of MoPyC prostheses are satisfactory and complications associated are low. The use of stem auto-expansion as a mode of obtaining primary fixation in radial head arthroplasty appears to be an effective solution for reducing the risk of painful loosening.

Radial Head Resection versus Arthroplasty in Unrepairable Comminuted Fractures Mason Type III and Type IV: A Systematic Review

Unrepairable comminuted fractures of the radial head Mason type III or type IV have poor outcomes when treated by open reduction and internal fixation. Radial head resection has been proposed as good option for surgical treatment, while in the last decades, the development of technology and design in radial head prosthesis has increased efficacy in prosthetic replacement. The present review was conducted to determine the best surgical treatment for comminuted radial head when ORIF is not possible. Better outcomes are reported for radial head arthroplasty in terms of elbow stability, range of motion, pain, and fewer complications compared to radial head excision. Nevertheless, radial head resection still can be considered an option of treatment in isolated radial head fractures with no associated ligament injuries lesion of ligaments or in case of older patients with low demanding function.

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.

Tight-fitting radial head prosthesis: does stem size help prevent painful loosening?

INTRODUCTION

The most common reason for removal of well-fixed radial head prostheses is painful loosening. We hypothesised that short-stemmed prostheses, used for radial head arthroplasty, are not associated with an increased risk of implant loosening.

METHODS

From 2002 to 2014, 65 patients were enrolled in a retrospective single-centre study. The radial head prostheses were classified as having either a long (30-mm) or short (16- to 22-mm) stem. The long-stemmed implants comprised 30 GUEPAR® DePuy Synthes (West Chester, PA, USA) and 20 Evolutive® Aston Medical (Saint-Etienne, France) devices; the short-stemmed implants comprised nine RECON and six STANDARD rHead® SBI-Stryker (Morrisville, PA, USA) devices. At last follow-up, clinical (range of motion, Disabilities of the Arm, Shoulder, and Hand score, Mayo Elbow Performance score) and radiographic (osteolysis) outcomes were assessed.

RESULTS

At a mean follow-up of 76.78 months (24-141), the rate of painful loosening [6 (40%) vs 8 (16%), p = 0.047] and osteolysis [12 (80%) vs 23 (46%), p = 0.02] were significantly higher in patients with short-stemmed versus long-stemmed implants. Despite the significant difference in loosening between stems as groups, individual stem length was not determined.

CONCLUSIONS

Tight-fitting implants with short stems are more prone to painful loosening.

Mid-term outcomes of 77 modular radial head prostheses

AIMS

Radial head arthroplasty (RHA) may be used in the treatment of non-reconstructable radial head fractures. The aim of this study was to evaluate the mid-term clinical and radiographic results of RHA.

PATIENTS AND METHODS

Between 2002 and 2014, 77 RHAs were implanted in 54 men and 23 women with either acute injuries (54) or with traumatic sequelae (23) of a fracture of the radial head. Four designs of RHA were used, including the Guepar (Small Bone Innovations (SBi)/Stryker; 36), Evolutive (Aston Medical; 24), rHead RECON (SBi/Stryker; ten) or rHead STANDARD (SBi/Stryker; 7) prostheses. The mean follow-up was 74.0 months (standard deviation (sd) 38.6; 24 to 141). The indication for further surgery, range of movement, mean Mayo Elbow Performance (MEP) score, quick Disabilities of the Arm, Shoulder and Hand (quickDASH) score, osteolysis and positioning of the implant were also assessed according to the design, and acute or delayed use.

RESULTS

The mean MEP and quickDASH scores were 90.2 (sd 14; 45 to 100), and 14.0 points (sd 12; 1.2 to 52.5), respectively. There were no significant differences between RHA performed in acute or delayed fashion. There were 30 re-operations (19 with, and 11 without removal of the implant) during the first three post-operative years. Painful loosening was the primary indication for removal in 14 patients. Short-stemmed prostheses (16 mm to 22 mm in length) were also associated with an increased risk of painful loosening (odds ratio 3.54 (1.02 to 12.2), p = 0.045). Radiocapitellar instability was the primary indication for re-operation with retention of the implant (5). The overall survival of the RHA, free from re-operation, was 60.8% (sd 5.7%) at ten years.

CONCLUSION

Bipolar and press-fit RHA gives unsatisfactory mid-term outcomes in the treatment of acute fractures of the radial head or their sequelae. The outcome may vary according to the design of the implant. The rate of re-operation during the first three years is predictive of the long-term survival in tight-fitting RHAs. Cite this article: Bone Joint J 2017;99-B1197-1203.

Results of cementless total elbow arthroplasty using the Discovery elbow system at a mean follow-up of 61.8 months

BACKGROUND

The available literature on the use of a cementless total elbow arthroplasty (TEA) design and its results are limited. This clinical study reports the outcome of the cementless Discovery elbow system.

METHODS

Patients were operated on by a single surgeon between 2007 and 2014. Nineteen patients (20 elbows) were available for review, 2 women (1 bilateral TEA) and 17 men. The age of the patients ranged from 27 to 75 years (mean, 48 years). The mean follow-up was 61.8 months (range, 12-156 months). Patients were assessed for range of motion, pain, and satisfaction level. Outcome scores included the Mayo Elbow Performance Score, the Liverpool Elbow Score, and the 12-Item Short Form Health Survey (version 1). Radiographs were reviewed to evaluate for loosening.

RESULTS

The mean Mayo Elbow Performance Score was 77.25, and the mean Liverpool Elbow Score was 6.76. The mean flexion range was 123°, and the mean extension lag was 35°. The mean pronation was 59°, and the mean supination was 58°. On radiologic evaluation, there were no signs of loosening; however, in 2 cases, nonprogressive radiolucent lines were observed. No signs of infection were detected at final follow-up, and no elbows were revised. More than 90% of patients were satisfied with the overall outcome.

CONCLUSION

The cementless TEA seems to be a reliable option for treatment of varying elbow diseases. Long-term results are needed to assess the survivorship of this design.

A Complicated Course of a Coronal Shear Fracture Type IV of the Distal Part of Humerus Resulting in Resurfacing Radiocapitellar Joint Replacement

Background:

Coronal shear fracture type IV of the distal part of humerus is a very rare injury with articular complexity potentially leading to posttraumatic osteoarthritis. One option for surgical treatment of advanced unicompartmental radiocapitellar osteoarthritis is resurfacing radiocapitellar joint replacement.

Method:

A 62-year- old female sustained a coronal shear fracture type IV of the distal part of left humerus that was primarily treated with open reduction and internal fixation using headless compression screws. Three years postoperatively, there was a migration of one screw into radiocapitellar joint that led to circular deep cartilage defect of radial head. Four years after ORIF, a distinctive radiocapitellar osteoarthritis has evolved leading to a resurfacing radiocapitellar joint replacement using the Lateral Resurfacing Elbow^TM (LRE) system.

Result:

At the 2-year follow-up after that procedure, there was an excellent subjective and functional outcome. Radiographically, no loosening or subsidence of implant without any signs of overstuffing could be found. The patient reported that she would have the same procedure again.

Conclusion:

The goal of unicompartmental radiocapitellar replacement is to obtain stability in elbow joint by avoiding cubitus valgus with subsequent instability of the distal radioulnar joint, and it does not alter the unaffected ulnohumeral joint. Additionally, the feature of the LRE^TM system is that the radial head is not excised, and so will receive the anatomical length of the overall radius articulating with the capitellum by preserving the annular ligament. In the literature only three publications could be found in which short-term results with the use of the LRE^TM system have been described. Hence, further studies are needed to validate this concept.

Mason type III radial head fractures treated by anatomic radial head arthroplasty: Is this a safe treatment option?

BACKGROUND

Radial head fractures make up approximately 3% of all fractures and they are the most common elbow fracture in adults. Replacement through arthroplasty is the recommended treatment in the context of unstable elbow injury and comminuted radial head fracture. The midterm clinical, functional, and radiographic results in patients treated with anatomic radial head arthroplasty for a Mason type III radial head fracture are presented.

MATERIAL AND METHODS

We performed a retrospective search of our facility's prospective trauma database to identify all skeletally mature patients who were treated by primary radial head replacement or open reduction and internal fixation following an acute radial head fracture. Inclusion criteria were Mason type III fractures and anatomic radial head arthroplasty (RHA). All the patients included were evaluated using a standard postoperative protocol including clinical and radiographic evaluation at 1, 3 and 12 months of follow-up. All the patients were reviewed clinically at an average of 30 months' follow-up.

RESULTS

Forty-one subjects (32 Mason type III and 9 Mason IV fractures) were treated with anatomic RHA (Acumed, Hillsboro, OR, USA). Of these, two patients (1 Mason type III and 1 Mason type IV) were excluded from the analysis because severe cognitive impairment. Moreover, we decided to exclude the subjects with a Mason type IV fracture to obtain a more homogeneous sample. Therefore, 31 patients with a Mason type III fracture were included in this study. Based on the Mayo Elbow Performance Score, excellent results were obtained in 24 (77%) patients, good in 3 (10%) and fair in 4 (13%) patients. Heterotopic ossification was reported in 8 patients (26% of cases). The final elbow flexion-extension range of motion was of 112°, with a mean flexion of 125°. The final forearm rotational range of motion was 134° with a mean pronation of 68° and a mean supination of 66°.

DISCUSSION

Anatomic radial head replacement leads to a good functional recovery, even in the presence of severe instability, such as coronoid fractures and LUCL injury. However, patients should be informed of the high number of adverse events (mainly heterotopic ossification) following this treatment.

LEVEL OF EVIDENCE

Therapeutic IV.

Comminuted fractures of the radial head: resection or prosthesis?

INTRODUCTION

At present, surgical treatment of comminuted radial head fractures without associated instability continues to be controversial. When anatomical reconstruction is not possible, radial head excision is performed. However, the appearance of long-term complications with this technique, along with the development of new radial head implants situates arthroplasty as a promising surgical alternative. The purpose of the present study was to compare the mid-term functional outcomes of both techniques.

MATERIALS AND METHODS

A retrospective study was performed between 2002 and 2011 on 25 Mason type-III fractures, 11 patients treated with primary radial head resection and 14 who received treatment of the fracture with metal prosthesis. At the end of follow-up, patients were contacted and outcomes evaluated according to: Mayo Elbow Performance Score (MEPS), the Disabilities of the Arm, Shoulder and Hand score (DASH) and strength measurement. Radiographic assessment (proximal migration of the radius, osteoarthritic changes, and signs of prosthesis loosening) was also performed.

RESULTS

The average age of the sample was 53.7 years in the resection group, and 54.4 years in the replacement group, with a mean follow-up of 60.3 and 42 months respectively. According to the MEPS scale, there were 6 excellent cases, 3 good and 2 acceptable in the resection group, and 6 excellent cases, 3 good, 3 acceptable, and 2 poor in the prosthesis group. The mean DASH score were 13.5, and 24.8 for the resection and the replacement group respectively. We found one postoperative complication in the resection group (stiffness and valgus instability) and 6 in the replacement group: 3 of joint stiffness, 1 case of prosthesis breakage, and 2 neurological injuries.

CONCLUSIONS

Although this is a retrospective study, the high complication rate occurring after radial head replacement in comparison with radial head resection, as well as good functional results obtained with this last technique, leads us to recommend it for comminuted radial head fractures without associated instability.

Elbow arthroplasty: where are we today? A narrative review

Background The elbow joint is a complex compound articulation, with a linking role within the upper limb kinematics. Its hinge function allows for proper placement of our working instrument (the hand) in the space surrounding us, directed by the shoulder joint. Both reliable mobility and stability are essential elements to allow for consistent bridging of the distance we aim to achieve in common daily activities. Sufficient flexion and extension are required to ensure both the patients' independence and the dignity. Next to the hinge, a radio-ulnar rotation with precise co-operation of forearm and wrist spin enhances the linking function with accurate precision instrument manipulation. Arthritis of the elbow joint or cubarthritis, whether primary or secondary, may not be as highly prevalent as hip or knee arthritis, but its impact on daily live certainly cannot be underestimated. Methods Current treatment options for failing cubarthritis are reviewed. Results Surgical techniques to reconstruct or replace the elbow joint are currently increasingly efficient with mounting long-term outcome reports. Debridement techniques including open or arthroscopic Outerbridge-Kashiwaghi procedure often delays joint replacement. Implants for joint arthroplasty focus on the ulna-humeral joint mostly with semi-constrained linked techniques, but there is a trend towards total joint replacement including the radiocapitellar joint. Conclusion In this independent review article, elbow joint failure due to cubarthritis and an overview of its current state-of-the-art orthopaedic treatment algorithm is presented, with its indications, advantages, risks and outcome.

One-year results of cemented bipolar radial head prostheses for comminuted radial head fractures

INTRODUCTION

Comminuted radial head fractures (Mason type III) continue to pose a challenge to orthopedic surgeons. When internal fixation is not possible, radial head arthroplasty has been advocated as the treatment of choice. The purpose of this retrospective study was to evaluate clinical and radiological short-term results of patients with Mason type III radial head fractures treated with a cemented bipolar radial prosthesis.

METHODS

Twelve patients received cemented bipolar radial head hemiarthroplasty for comminuted radial head fractures. In all patients a CT scan was obtained prior to surgical treatment to assess all associated injuries. Postoperatively an early motion protocol was applied. All patients were evaluated clinically and radiologically at an average of 12.7 months.

RESULTS

According to the Mayo Modified Wrist Score, the Mayo Elbow Performance Score, the functional rating index of Broberg and Morrey, and the DASH Score good to excellent results were obtained. Grip strength and range of motion were almost at the level of the unaffected contralateral side. Patient satisfaction was high, no instability or signs of loosening of the implant, and only mild signs of osteoarthritis were seen.

CONCLUSION

Overall good to excellent short-term results for primary arthroplasty for comminuted radial head fractures were observed. These encouraging results warrant the conduction of further studies with long-term follow-up and more cases to see if these short-term results can be maintained over time.

Clinical and radiologic outcomes of pyrocarbon radial head prosthesis: midterm results

BACKGROUND

The modular pyrocarbon (MoPyC) radial head prosthesis (Tornier, Saint-Ismier, France) is a monoblock modular radial head prosthesis. This study assessed midterm outcomes after implantation of the prosthesis.

MATERIALS

A retrospective study was conducted of a consecutive cohort of 65 patients who underwent radial head replacement with the MoPyC prosthesis from January 2006 to April 2013. Indications were fractures, early or late failures from orthopedic or fixation treatments, and revisions after another implant. Patients were observed for >2 years for range of motion, pain, and stability; function by the Mayo Elbow Performance Score (total score, 100) and grip strength were assessed. Quality of stem implantation, bone resorption around the neck, and periprosthetic lucency were noted and quantified on radiographs. Capitellum shape and density as well as humeroulnar aspect (river delta sign) were evaluated. Complications and revision procedures were noted.

RESULTS

We evaluated 52 of 65 patients (mean follow-up, 46 ± 20 months; range, 24-108). The Mayo Elbow Performance Score was 96 ± 7; pain score, 42 ± 7/45; and motion score, 18 ± 2/20. Function and stability were excellent. Radiology revealed 92% of patients with cortical resorption around the neck without mechanical failure. Bone resorption was mostly anterior and lateral; it resolved within the first year and thereafter was stable. Eight patients underwent revision surgery for stiffness. No implant failures were noted.

CONCLUSION

Results of the MoPyC radial head prosthesis appear to be satisfactory. Bone resorption around the neck (stress shielding) is frequent and stable after 1 year and does not impair stem fixation. The MoPyC prosthesis appears to be a reliable solution for replacing the radial head.

Outcome after total elbow arthroplasty: a retrospective study of 167 procedures performed from 1981 to 2008

BACKGROUND

Total elbow arthroplasties (TEAs) are traditionally grouped into linked and unlinked design. The aim was to analyze the difference in clinical outcomes after TEA based on implant design and indication for surgery and to evaluate primary and revision TEAs.

METHODS

A total of 167 TEAs (126 primary and 41 revision TEAs) in 141 patients were evaluated with patient-reported outcome measure by the Oxford Elbow Score (OES) and clinically assessed with the Mayo Elbow Performance Score (MEPS), range of motion (ROM), and standard radiographs.

RESULTS

The mean follow-up was 10.5 years for primary and 7.5 years for revision TEAs. There was no difference in OES or MEPS between linked and unlinked primary TEAs. The OES score in the social-psychological domain was significantly lower in TEAs performed due to fracture (67) compared with rheumatoid arthritis (81; P = .025). ROM in extension-flexion was 116° for primary linked TEAs compared with 110° for primary unlinked TEAs (P = .02). Revision TEAs were associated with a poorer outcome in OES, MEPS, and ROM compared with primary TEAs. Radiographic signs of loosening were seen in 15 primary and 7 revision TEAs at follow-up.

CONCLUSIONS

We found no clinically significant differences in outcomes after linked or unlinked TEAs. Patients with TEAs due to fracture had poorer social-psychological results than rheumatoid arthritis patients. The results after revision surgery were significantly inferior compared with primary procedures. The OES contributes to the evaluations of the outcome after TEA surgery with a nuanced picture of the patient's perception.

The effect of prosthetic radial head geometry on the distribution and magnitude of radiocapitellar joint contact pressures

PURPOSE

To determine if radiocapitellar contact pressures would be elevated with nonanatomical (circular) prostheses over those mimicking native anatomy and if such pressures would be related to the depth and contour of the articular dish and to the pattern of prosthetic articulation against the lateral trochlear ridge.

METHODS

Three commercially available circular radial head designs were compared with an anatomical radial head and 2 modified anatomical prototype radial head designs in 10 cadaveric specimens. Each prosthesis and specimen combination was loaded in neutral rotation and maximal extension with a custom testing apparatus while measuring contact areas and pressures using thin-film pressure sensors.

RESULTS

Anatomical radial head prototype 2 had similar radiocapitellar contact areas and mean pressures as the native radial head; all other designs showed significant decreases in contact area and increased mean pressures. Peak contact pressures were also measured and were significantly elevated with all prostheses tested. Anatomical designs are statistically more likely to mimic normal contact with the lateral trochlear ridge and its adjacent sulcus than circular prostheses. They are also significantly less likely to have contact pressures above the 5 MPa threshold that is thought to be harmful to cartilage. The depth of the articular dish had a significant effect on contact area and pressure.

CONCLUSIONS

Commercially available radial head prostheses demonstrated reduced radiocapitellar contact areas and elevated contact pressures during compressive loading. These were significantly greater with symmetrical circular prostheses than with asymmetrical elliptical designs. The prosthesis that best mimicked native contact behavior was the anatomical radial head prototype 2 owing to its design for articulating with the capitellum, the lateral trochlear ridge, and the sulcus between.

CLINICAL RELEVANCE

Because radial head prostheses have the potential to cause capitellar erosion or arthritic change, those with lower contact pressures may lead to fewer such complications.

Medium-term clinical results of a linked total elbow replacement system

Medium-term results of the Discovery elbow replacement are presented. We reviewed 51 consecutive primary Discovery total elbow replacements (TERs) implanted in 48 patients. The mean age of the patients was 69.2 years (49 to 92), there were 19 males and 32 females (37%:63%) The mean follow-up was 40.6 months (24 to 69). A total of six patients were lost to follow-up. Statistically significant improvements in range movement and Oxford Elbow Score were found (p < 0.001). Radiolucent lines were much more common in, and aseptic loosening was exclusive to, the humeral component. Kaplan-Meier survivorship at five years was 92.2% (95% CI 74.5% to 96.4%) for aseptic loosening. In four TERs, periprosthetic infection occurred resulting in failure. A statistically significant association between infection and increased BMI was found (p = 0.0268). Triceps failure was more frequent after the Mayo surgical approach and TER performed after previous trauma surgery. No failures of the implant were noted. Our comparison shows that the Discovery has early clinical results that are similar to other semi-constrained TERs. We found continued radiological surveillance with particular focus on humeral lucency is warranted and has not previously been reported. Despite advances in the design of total elbow replacement prostheses, rates of complication remain high.

Radiocapitellar joint contact pressures following radial head arthroplasty

PURPOSE

To determine the radial head arthroplasty length that best replicates the native radiocapitellar contact pressure.

METHODS

Eight cadaveric elbows (4 matched pairs) with an average age of 73 years were tested. All specimens were ligamentously stable and without visible cartilage wear. Radiocapitellar contact pressures were digitally analyzed during simulated joint loading at 0°, 45°, and 90° of elbow flexion and neutral rotation in the intact specimens and after ligament-preserving radial head arthroplasty at -2 mm, 0 mm, and +2 mm of the native length. The results were analyzed using 1-way analysis of variance and post hoc Tukey pairwise comparison tests.

RESULTS

Paired analysis demonstrated significantly decreased mean contact pressures when comparing the native versus the minus 2 groups. Significantly decreased maximum contact pressures were also noted between the native and the minus 2 groups. Examining the mean contact pressures showed no significant difference between the native and the zero group and the native and the plus 2 groups. As for the maximum contact pressures, there was also no significant difference between the native and the zero group and the native and the plus 2 group.

CONCLUSIONS

Up to 2 mm of overlengthening may be tolerated under simulated loading conditions without significantly increasing contact pressures of the radiocapitellar joint. Surgeons can use this knowledge along with radiographic parameters and intraoperative examination of elbow stability to gauge the appropriate size of the radial head implant to be used in order to decrease the risk of overstuffing the joint and minimizing radiocapitellar chondral wear.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.