Proximal radial drift following radial head resection

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

Background

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

Methods

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

Results

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

Discussion

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

Chondrosarcoma of the proximal radius treated by wide resection and reconstructed by 3D printed implant: A case report and description of surgical technique

Introduction

Chondrosarcoma is the second most common primary malignancy of bone that can occur in multiple locations in the skeleton. It has been rarely reported in the proximal radius. While surgical resection is the primary treatment modality for individuals with localized disease, reconstruction can be challenging in the elbow joint due to its complex anatomy. 3D printing technology can be used in such complex cases to restore the normal anatomy after resection.

Case presentation

We present a case of mesenchymal chondrosarcoma in a 33-year-old male occurring in the proximal radius, restricting his elbow motion. That was resected and reconstructed using 3D modeling. Restoring a functional range of motion without instability.

Discussion

Many surgical options for chondrosarcoma presented over the years including en bloc resection, resection with or without reconstruction, or amputation. Usage of 3D modeling in the orthopedic surgery field is relatively new and it can be used in pre-operative planning and shortens surgical time. 3D printing in our case helped in obtaining a full range of motion (flexion, extension, pronation, and supination) for the patient.

Conclusion

It's important to reconstruct elbow joint support structure and function after resection of such a large malignant tumor in young patients. We used 3D printed implant to maintain a functional limb and it was an excellent alternative treatment.

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Chondrosarcoma occurring in the proximal radius is very rare. Up to our knowledge, this is the second case report.

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We report a case of proximal radius chondrosarcoma managed by reconstruction with Three-Dimension printed implant.

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3D printing in the field of orthopedic surgery is relatively new and has upscaled medical management.

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A description of a surgical technique to reconstruct proximal radius and maintaining full range of motion of the elbow.

Does Radial Head Resection Impair Hand and Wrist Function? A Long-Term Follow-Up

OBJECTIVE

To evaluate the long-term outcome in patients after radial head resection surgery for isolated Mason type III radial head fractures.

DESIGN

An observational retrospective case series.

SETTING

A Hand and Upper-Extremity Surgery Unit in a tertiary care center.

PATIENTS

Data were collected from files of patients who were operated between the years 1980 and 2020. Of 352 patients who underwent surgery for radial head fractures, 25 patients were eligible and were enrolled in the study.

INTERVENTION

All participants underwent radial head resection surgery and a follow-up clinical and radiographic evaluation by 2 senior orthopaedic surgeons.

OUTCOME MEASUREMENTS

Objective evaluation included active range of motion of the elbow and wrist joints, ulnohumeral angle, key pinch and grip measurements, and radiographic imaging of elbow and wrist joints. Subjective evaluation included visual analog scale measurements, disability of arm shoulder and hand questionnaire, Mayo wrist score, Michigan hand outcome, and Oxford elbow score.

RESULTS

The mean follow-up was 18 years. Mean elbow range of motion and mean grip strength were lower in the operated hand, as compared to the contralateral hand. Mean proximal radial migration was 1.6 mm. Mean results of visual analog scale, disability of arm shoulder and hand, Mayo wrist score, Michigan hand outcome, and Oxford elbow score indicated good functional outcome and high patient satisfaction.

CONCLUSIONS

In our study population, long-term functional outcomes after radial head resection were encouraging. Thus, this procedure may be considered as a surgical alternative when radial head reconstruction or replacement fails.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

Radial Head Resection and Corium Interposition Arthroplasty in Skeletally Immature Patients With Isolated Posttraumatic Radial Head Arthrosis

Radiocapitellar arthrosis represents a serious sequela of pediatric elbow injuries. Although persistent pain and disability are not uncommon in such cases, treatment remains controversial. The present study aimed to review the clinical outcomes after a new surgical treatment with partial radial head resection and corium interposition arthroplasty. To date, 3 adolescent cases underwent the surgical procedure and postoperative care. Thorough clinical and radiographic follow-up was performed. The mean age at the time of surgery was 14.4 years (range, 13 to 16 y) and mean duration of follow-up was 19 months (range, 12 to 29 mo). The postoperative range of motion was maintained in all cases. The outcome was rated as excellent in all 3 patients for the Disabilities of the Arm, Shoulder and Hand score (mean, 3; range, 0 to 6.7) and Mayo Elbow Performance Score (mean, 92; range, 80 to 100). The mean Timmermann score; however, was still rated as fair despite marked improvements (mean, 153; range, 145 to 165). No complications such as elbow stiffness, osteophytes formation, radial head overgrowth, or proximal radius migration occurred. In pediatric isolated posttraumatic radiocapitellar arthrosis, we believe that radial head resection and corium interposition arthroplasty is an effective salvage procedure to alleviate symptoms and maintain elbow function with good to excellent clinical outcomes and no proximal migration of the radius.

Post-traumatic proximal radioulnar synostosis: results of surgical treatment and review of the literature

BACKGROUND

Post-traumatic proximal radioulnar synostosis is a very rare and disabling condition whose surgical treatment has traditionally been viewed with pessimism. The results of the few case series in the literature are conflicting. Our aims were (1) to describe the clinical results of a case series treated surgically by a single elbow surgeon and (2) to review the literature.

METHODS

Twelve patients were evaluated. Preoperative radiographs and computed tomography scans were performed. According to the Viola and Hastings classification, there was 1 case of type IC synostosis; 3, type IIA; 2, type IIIA; and 8, type IIIB. Two patients had a double synostosis. The synostosis was excised in 10 cases; in addition, radial head excision, radial head arthroplasty, and proximal radial diaphyseal resection were performed in 1, 3, and 2 cases, respectively. The Mayo Elbow Performance Score, modified American Shoulder and Elbow Surgeons score, and QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score were used for the preoperative and postoperative evaluation. The nonparametric Wilcoxon signed rank test was used for the statistical analysis.

RESULTS

The mean follow-up period was 20.5 months. The final mean extension-flexion and pronation-supination arcs were 116° and 123°, respectively. Significant improvements were found in the Mayo Elbow Performance Score (P = .005), modified American Shoulder and Elbow Surgeons score (P = .012), and QuickDASH score (P = .002), with mean values of 24, 28, and 17, respectively. One synostosis recurrence and one late disassembly of the radial head arthroplasty were observed.

CONCLUSIONS

Post-traumatic proximal radioulnar synostosis surgery is effective, but careful preoperative planning based on the pathoanatomic characteristics of each type of synostosis and associated lesions is mandatory. Synostosis excision is performed in most cases, whereas additional surgical procedures should be considered in selected cases.

Surgical treatment of the radial head is critical to the outcome of Monteggia-like lesions

Aims

The aim of this study was to evaluate the outcome of Monteggia-like lesions at midterm follow-up and to determine whether the surgical treatment of the radial head influences the clinical and radiological results.

Patients and Methods

A total of 78 patients with a Monteggia-like lesion, including 44 women and 34 men with a mean age of 54.7 years (19 to 80), were available for assessment after a mean 4.6 years (2 to 9.2). The outcome was assessed using the Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), Mayo Modified Wrist Score (MMWS), and The Disabilities of the Arm, Shoulder and Hand (DASH) score. Radiographs were analyzed for all patients. A total of 12 Mason type I, 16 type II, and 36 type III fractures were included. Surgical treatment consisted of screw fixation for all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) or excision was performed if reconstruction was not possible.

Results

The mean MEPS was 88.9 (40 to 100), mean OES was 40.1 (25 to 48), mean MMWS was 88.1 (50 to 100), mean DASH score was 14.7 (0 to 60.2), and mean movement was 114° (sd 27) in extension/flexion and 155° (sd 37) in pronation/supination. Mason III fractures, particularly those with an associated coronoid fracture treated with RHA, had a significantly poorer outcome. Suboptimal results were also identified in patients who had degenerative changes or heterotopic ossification on their latest radiograph. In contrast, all patients with successful radial head reconstruction or excision had a good outcome.

Conclusion

Good outcomes can be achieved in Monteggia-like lesions with Mason II and III fractures, when reconstruction is possible. Otherwise, RHA is a reliable option with satisfactory outcomes, especially in patients with ligamenteous instability. Whether the radial head should be excised remains debatable, although good results were achieved in patients with ligamentous stability and in those with complications after RHA. Cite this article: Bone Joint J 2019;101-B:1512–1519

Idiopathic anterior dislocation of the radial head: symptoms, radiographic findings, and management of 8 patients

BACKGROUND

Radial head dislocation may occur during trauma or in association with congenital diseases, or it may be developmental or idiopathic. Reports of idiopathic dislocation of the radial head have been scarce. The symptoms, radiographic findings, and management of idiopathic dislocation of the radial head have not been well described in the literature.

METHODS

During the past 28 years, we have encountered 8 cases of idiopathic anterior dislocation of the radial head (mean patient age, 12.5 years). In only 1 case did the patient and/or the patient's parents recall any preceding trauma or injury to the affected limb. Patients' complaints included a bulging mass, pain, and limited elbow flexion. Radiographically, the shape of the radial head was flat or slightly convex. Seven of the patients were treated with open reduction of the radial head and angulation osteotomy of the ulna. The other patient's radial head was stabilized without osteotomy.

RESULTS

The mean postoperative follow-up period was 4.5 years. In patients whose elbow flexion was limited before surgery, improvement to more than 125° occurred. The bulging mass in the cubital fossa disappeared. None of the patients complained of disability during activities of daily living or sports participation. Radiographically, the radial head remained in the reduced position in all patients in whom open reduction of the radial head with angulation osteotomy of the ulna was performed.

CONCLUSIONS

We have described the symptoms, radiographic characteristics, and treatment of idiopathic anterior dislocation of the radial head. Open reduction of the radial head combined with angulation osteotomy of the ulna yielded favorable results both clinically and radiographically.

Ipsilateral proximal and distal radius fractures with unstable elbow joint: Which should we address first?

Simultaneous ipsilateral fractures involving radial head and distal end of radius are uncommon. We present our thoughts on which fracture should be addressed first. A 68-year-old lady sustained an ipsilateral fracture of the right radial head and distal end of radius following a fall. Clinically her right elbow was posteriorly dislocated and right wrist was deformed. Plain radiographs showed an intraarticular fracture of the distal end of radius and a comminution radial head fracture with a proximally migrated radius. Magnetic resonance imaging (MRI) showed no significant ligament injuries. We addressed her distal radius first with an anatomical locking plate followed by her radial head with a radial head replacement. Our rationale to treat the distal end radius: first was to obtain a correct alignment of Lister's tubercle and correct the distal radius height. Lister's tubercle was used to guide for the correct rotation of the radial head prosthesis. Correcting the distal end fracture radial height helped us with length selection of the radial head prosthesis and address the proximally migrated radial shaft and neck. Postoperative radiographs showed an acceptable reduction. The Cooney score was 75 at 3 months postoperatively, which was equivalent to a fair functional outcome.

Radial head arthroplasty for radial head fractures: a clinical and radiological comparison of monopolar and bipolar radial head arthroplasty at a mean follow-up of 6 years

PURPOSE

The purpose of this study was to compare clinical and radiographic outcomes of bipolar and monopolar radial head arthroplasty in treatment of radial head fracture at a mean follow-up of 6 years.

METHODS

A retrospective multicentre cohort study of 30 patients treated for unreconstructable radial head fractures. Patients were treated either with a cemented bipolar or an uncemented monopolar radial head arthroplasty. All patients included were evaluated with patient-rated outcome questionnaire, physical examination, and radiographic evaluation at a mean of 6 years (range, 2-12 years) postoperatively.

RESULTS

There was no statistical difference in QuickDASH between the bipolar or monopolar groups. The majority of patients had no to little pain during rest. Neither flexion nor extension of the injured arm was significantly affected by the type of prosthesis. None of the patients in the bipolar group had any secondary surgery at the time of follow-up. In the monopolar group, four patients required removal of the arthroplasty. Signs of ulnohumeral degenerative changes were seen in the majority of patients in both groups (55% in the monopolar group, 92% in the bipolar group).

CONCLUSION

In this retrospective cohort study comparing a bipolar and a monopolar radial head arthroplasty for treatment of radial head fractures, we found comparable functional outcome but more revision procedures in the monopolar group at a mean follow-up of 6 years.

Complications after radial head arthroplasty: a comparison between short-stemmed bipolar and monopolar long-stemmed osteointegrative rigidly fixed prostheses

INTRODUCTION

To date, only a few studies have compared radial head prostheses (RHP) and their different anchoring principles. The aim of this study was to characterize concomitant injuries, necessary adjuvant procedures, complications, and radiological findings after implantation of two different types of RHP.

METHODS

Sixty-six patients with radial head fractures were treated with MoPyC (Tornier/France, 50 mm stem, monopolar) or SBI rHead prostheses (Small Bone Innovations/USA, 22-mm stem, bipolar) and followed up over 42 months (16-64 months). Primary objective was the detection of different loosening and explantation rates. In addition to the revision rate and the reasons for revision, we also used radiological findings to assess the dynamics of lysis phenomena.

RESULTS

Thirty-five patients (mean age 48 years; 22-73 years) were treated with the MoPyC, and 31 patients (mean age 47 years, 19-69 years) with the rHead prosthesis. Of these, 98% had a Mason 3 or 4 type of radial head fracture, and 94% showed concomitant injuries, which were addressed in 89% of cases by adjuvant procedures. The surgical revision rate was 20% (rHead 23%; MoPyC 18%). Significantly more of the rHead prostheses had to be explanted compared to MoPyC prostheses because of painful loosening (16% vs. 3%; p = 0.029). Predictors of subsequent loosening were significant radiolucent lines in the RHP over the first six months and an increase in width by two and a half times within the first 50 days after implantation.

CONCLUSION

Complex radial head fractures are frequent and difficult to treat. The monopolar long-stemmed prosthesis showed significantly lower rates of painful loosening and explanation rates than the bipolar short-stemmed prosthesis.

The radiocapitellar synovial fold: a lateral anatomic landmark for sizing radial head arthroplasty

BACKGROUND

Successful radial head arthroplasty relies on reproduction of anatomy. We hypothesized that the radiocapitellar synovial fold could serve as a reference point in radial head prosthesis sizing. Our study aimed to define the relationship between the synovial fold and the radial head in elbows with and without lateral ulnar collateral ligament (LUCL) injury.

MATERIALS AND METHODS

We performed magnetic resonance imaging evaluation of 34 elbows to determine the normal relationship between the radiocapitellar synovial fold and the radial head. Next, we used cadaveric dissections to evaluate the anatomic relationships with the LUCL intact and disrupted, as well as in the setting of sizing with a radial head prosthesis. The fold-to-radial head distance (FRHD) was measured on all images and analyzed to determine the relationship of the synovial fold and radial head.

RESULTS

The FRHD in cadavers with an intact LUCL and native radial head measured an average of 1.5 mm proximal to the radial head. With the LUCL disrupted and a native radial head, the FRHD measured an average of 1.2 mm proximal to the radial head. The mean difference between the groups was 0.5 mm (P = .031), suggesting that the fold migrated distally in the cadavers with a disrupted LUCL.

CONCLUSION

The radiocapitellar synovial fold may be a helpful landmark for radial head sizing. The synovial fold is always just proximal to the articular surface of the radial head. Using this information, the surgeon can prevent overlengthening as the implant should not be placed proximal to the fold.

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.

Clinical outcomes of anconeus interposition arthroplasty after radial head resection in native and prosthetic radial heads

BACKGROUND

Radiocapitellar pathology after traumatic injury to the elbow can be challenging to treat. The anconeus interposition arthroplasty has been proposed to treat radiocapitellar or proximal radioulnar joint dysfunction and pain, or both. This study evaluated whether radial head excision (native or prosthetic), followed by an anconeus interposition arthroplasty, relieves pain and improves subjective and objective elbow function in patients with post-traumatic radiocapitellar pathology.

METHODS

A retrospective comparative case series was performed of 50 consecutive patients who underwent a native radial head excision or radial head implant excision, followed by an anconeus interposition arthroplasty. Clinical outcome scores, range of motion, and proximal radius migration were evaluated in patients with at least 2 years of follow-up.

RESULTS

Included were 23 patients (11 native and 12 prosthetic radial heads) with a mean age of 41 years. Average follow-up was 38 months. Overall, significant improvement was obtained in the Disabilities of the Arm, Shoulder and Hand and visual analog scale scores. Range of motion significantly improved from preoperatively to postoperatively. Patients with a native radial head excision scored better on the Single Assessment Numeric Evaluation (76.8 vs. 56.3, P = .037) and obtained significantly more flexion postoperatively (141° vs. 123°, P = .016). Mild wrist pain developed in 3 patients, but no further intervention was required. The overall complication rate was 13%, and 5 patients required reoperation.

CONCLUSIONS

Anconeus interposition arthroplasty performed after radial head resection in native and prosthetic groups is a viable adjunct in the operative treatment of patients with post-traumatic radiocapitellar pathology. However, whether anconeus interposition arthroplasty alone produced the favorable clinical results of this study was difficult to determine.

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.

Computer-Assisted Corrective Osteotomy of Malunited Pediatric Radial Neck Fractures-Three-Dimensional Postoperative Accuracy and Clinical Outcome

Neglected or incorrect treatment of pediatric radial neck fractures may lead to symptomatic malunions. Computer-assisted corrective osteotomies with patient-specific guides have been proposed as a promising technique for the reconstruction of malunited long bone deformities. The aim of this study was to evaluate the accuracy and clinical outcome of this technique in children with malunited fractures of the radial neck. Four children [2 boys, 2 girls; mean age 12 (10-16) years] underwent computer-assisted closing wedge osteotomy of the radial neck. The contralateral uninjured side was used as a reconstruction template. Computed tomography were performed 8 weeks postoperatively to confirm bony consolidation and to quantify residual 3D rotational and translational displacement error. Clinical outcome [pain, range of motion (ROM)] and overall satisfaction were documented. Preoperative subluxation of the radial head could be corrected in 2 of 3 patients. One patient had to be revised because of secondary traumatic loss of reduction. At the last follow-up [mean 16 (range, 12-24) months], all patients were pain free for activities of daily living (preoperative pain: visual analog scale 6). Pain during sport activities could be substantially reduced (visual analog scale 8→2). Although the procedure failed to improve ROM, none of the patients had limitations regarding work, daily, or sports activities. Yet, restricted ROM was considered as a cosmetic problem in 1 patient. Full consolidation of the osteotomy site, with no signs of avascular necrosis of the radial head, was achieved in all patients. The deformity could be substantially reduced, from a 3D angle of 13-40 degrees to 3-7 degrees (58%-89% deformity correction). Computer-assisted corrective osteotomy is a novel technique for the treatment of radial neck malunions that led to adequate pain reduction and 3D accuracy of deformity correction in our small case series. Despite the lack of improved ROM, all patients were satisfied and would undergo the same procedure again.

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.

Radial head prosthesis: results overview

Background/purpose

Radial head replacement is frequently used in treatment of radial head fractures or sequela. Impossibility to restore a correct anatomy, acute elbow traumatic instability and failure of osteosynthesis hardware are the most common indications. The authors describe their case studies and results on the implantation of various radial head prostheses.

Materials

Between June 2005 and June 2016, 28 radial head prostheses were implanted in the same number of patients with an average follow-up of 49 months (6–104). Indications for implantation were: Mason type III and IV radial head fractures and post-traumatic arthritis due to failure of previous treatments. Monopolar prostheses were used and were press-fit implanted via Kaplan’s lateral access and Kocher’s anconeus approach to the humeroradial joint. At the follow-up, assessments were made of the pain, according to the visual analogic scale, range of motion (ROM), stability and functionality according to the Mayo Elbow Performance Score, presence of osteolysis and mobilization during radiography tests, personal satisfaction of the patients, Disabilities of the Arm, Shoulder and Hand and Patient-Rated Wrist Evaluation outcomes measurements.

Results

At the follow-up, we recorded an average level of pain of 1.8 in patients under acute treatments for radial head fractures and a marked reduction in the remaining cases from 6.7 to 2.1. ROM was found on average to be 107° of flexion–extension and 159° of pronosupination. Personal satisfaction was good–excellent in 23 cases. There was no case of infection; removal of the implant was necessary in three cases due to mobilization of the stem and oversized implants. In six cases, bone resorption was seen at the level of the prosthetic collar and it was in all cases asymptomatic.

Conclusions

The results of this study suggest that the use of prostheses, if well positioned, is a valid solution in the treatment of secondary arthritis and fractures of the radial head with poor prognosis, with good results in the reduction of pain, recovery of movement and improved quality of life.

Outcome of Radial Head Arthroplasty in Comminuted Radial Head Fractures: Short and Midterm Results

Background:

Comminuted radial head fractures are often associated with secondary injuries and elbow instability.

Objectives:

The aim of this retrospective study was to evaluate how well the modular metallic radial head implant EVOLVE® prosthesis restores functional range of motion (ROM) and stability of the elbow in acute care.

Patients and Methods:

Eighty-five patients with comminuted radial head fractures and associated injuries received treatment with an EVOLVE® prosthesis between May 2001 and November 2009. Seventy-five patients were available for follow-up. On average, patients were followed for 41.5 months (33.0: 4.0 - 93.0). Outcome assessment was done on the basis of pain, ROM, strength, radiographic findings, and functional rating scores such as Broberg and Morrey, the Mayo elbow performance index (MEPI), and disabilities of the arm, shoulder and hand (DASH). Our study is currently the largest analysis of clinical outcome of a modular radial head replacement in the literature.

Results:

Overall, there were 2 (2.7%) Mason II fractures, 21 (28%) Mason III fractures, and 52 (69.3%) Mason IV fractures. Arbeitsgemeinschaft fur osteosynthesefragen (AO) classification was also determined. Of the 85 patients in our study, 75 were available for follow-up. Follow-up averaged 41.5 months (range, 4 - 93 months). Average scores for the cohort were as follows: Morrey, 85.7 (median 90.2; range 44.4 - 100); MEPI, 83.3 (85.0; 40.0 - 100); and DASH 26.1 points (22.5; 0.0 - 75.8). Mean flexion/extension in the affected joint was 125.7°/16.5°/0° in comparison to the noninjured side 138.5°/0°/1.2°. Mean pronation/supination was 70.5°/0°/67.1° in comparison to the noninjured side 83.6°/0°/84.3°. Handgrip strength of the injured compared to the non-injured arm was 78.8%. The following complications were also documented: 58 patients had periprosthetic radioluceny shown to be neither clinically significant nor relevant according to evaluated scores; 26 patients had moderate or severe periarticular ossification, and scored substantially worse according to MEPI and Morrey. Four patients required revisional surgery due to loosening of the prosthesis and chronic pain. In addition, one patient required a neurolysis of the ulnaris nerve, one developed a neobursa, and one had extensive swelling and blistering. The time interval between injury and treatment appeared to have an effect on results. Thirty-five patients were treated within the first 5 days after accident and showed better results than the 40 patients who were treated after 5 days.

Conclusions:

Comminuted radial head fractures with elbow instability can be treated well with a modular radial head prosthesis, which restores stability in acute treatment. The modular radial head arthroplasty used in this study showed promising findings in short to midterm results.

Resection arthroplasty for Mason type III radial head fractures yield good clinical but poor radiological results in the long term

Long-term clinical and radiographic outcomes of primary resection for Mason type III radial head fractures were evaluated in 13 patients (14 elbows) with a mean age of 38.8 years (range, 20-67 years) at the time of surgery. All patients had isolated radial head fractures without associated injuries. Mean follow-up was 14.7 years (range, 9-26 years). Proximal migration of the radius and the carrying angle were measured, and radiographs were reviewed for degenerative elbow and wrist arthritis and periarticular ossification. Five results were excellent and 9 were good. In 8 cases, the radii had migrated proximally and the carrying angle had increased an average 6.3°; the increases in both ulnar variance and the carrying angle were significant, and a significant negative correlation was found between the carrying angles and the clinical scores. Degenerative changes occurred in 8 elbows and 4 wrists, and periarticular heterotopic ossification was present in 3 elbows. Despite the satisfactory long-term outcomes, radial head resection resulted in proximal migration of the radius and an increase in the carrying angle; in addition, osteoarthritic changes in both elbows and wrists as well as periarticular heterotopic ossification were frequent findings without pronounced functional impairment.

The effect of excision of the radial head and metallic radial head replacement on the tension in the interosseous membrane

We measured the tension in the interosseous membrane in six cadaveric forearms using an in vitro forearm testing system with the native radial head, after excision of the radial head and after metallic radial head replacement. The tension almost doubled after excision of the radial head during simulated rotation of the forearm (p = 0.007). There was no significant difference in tension in the interosseous membrane between the native and radial head replacement states (p = 0.09). Maximal tension occurred in neutral rotation with both the native and the replaced radial head, but in pronation if the radial head was excised. Under an increasing axial load and with the forearm in a fixed position, the rate of increase in tension in the interosseous membrane was greater when the radial head was excised than for the native radial head or replacement states (p = 0.02). As there was no difference in tension between the native and radial head replacement states, a radial head replacement should provide a normal healing environment for the interosseous membrane after injury or following its reconstruction. Load sharing between the radius and ulna becomes normal after radial head Replacement. As excision of the radial head significantly increased the tension in the interosseous membrane it may potentially lead to its attritional failure over time.

Cite this article: Bone Joint J 2013;95-B:1383–7.

Fractures of the radial head

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred. This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence.

Elbow dislocation with irreparable fracture radial head

BACKGROUND

Treatment of elbow dislocation with irreparable radial head fracture needs replacement of radial head to achieve stability of elbow. An alternate method in cases of elbow dislocation with radial head fracture can be resection of radial head with repair of medial collateral ligament. We report a retrospective analysis of cases of elbow dislocation with irreparable radial head treated by excision head of radius and repair of MCL.

MATERIALS AND METHODS

Nine patients of elbow dislocation with associated irreparable fractures of the head of the radius were included in this analysis (6 F:3 M, Age: 35-47 years). Radial head excision was done through the lateral approach and MCL was sutured using no 3 Ethibond using medial approach. Above elbow plaster was given for 6 weeks and gradual mobilization was done thereafter. All patients were assessed at final followup using Mayo elbow performance score (MEPS).

RESULTS

Mean followup was 19.55 ± 7.12 months (range 14-36 months). There was no extension deficit when compared to opposite side with mean range of flexion of 138.8° ± 6.97° (range 130 -145°). Mean pronation was 87.7° ± 4.4° (range 80-90°) and mean supination was 87.7 ± 4.62° (range 80-90°). The mean MEPS was 98.8 ± 3.33 (range 90-100). No patient had pain, sensory complaints, subluxation or redislocation. All were able to carry out their daily activities without disability.

CONCLUSION

Radial head excision with MCL repair is an acceptable option for treatment of patients with elbow dislocation and irreparable radial head fracture.

Radial head fractures

Fractures of the radial head are the most common fractures in the elbow, and they frequently have associated ligamentous, cartilaginous, or other bony injuries. Clinical assessment and radiological investigation allow for accurate diagnosis and the formulation of a management plan. Undisplaced or minimally displaced fractures with no rotational block to motion can be treated nonoperatively with excellent results expected. The minimum amount of displacement in a partial articular radial head fracture required for open reduction and internal fixation to provide a superior outcome to nonoperative management is still unknown. Medium-term data suggest that patients with comminuted radial head fractures do well with radial head replacement.