Radial head fractures: indications and outcomes for radial head arthroplasty

Clinical study of suture anchors in the treatment of radial head fractures

BACKGROUND

This study aimed to analyze and study the clinical effect of suture anchors in the treatment of radial head fractures (RHFs).

METHODS

A total of 11 patients (five male and six female) with RHFs who were treated from March 2016 to June 2021 were included in this study. They were 17-61 (average 38.5) years old. In terms of the Johnston-Mason classification, two cases were type II, seven cases were type III, and two cases were type IV. All patients were treated with open reduction and anchor internal fixation.

RESULTS

All 11 patients were followed up, all incisions healed by first intention, and the duration of follow-up was 14-20 months. The average operation time was 40 ± 15 min. The clinical healing time was 4-6 (average 5) weeks. No patients had any complications, such as traumatic arthritis, malunion, nerve injury, joint stiffness, or incision infection. The clinical effects were evaluated according to the Mayo Elbow Performance Score. The scores of all 11 cases were 90-95, all excellent.

CONCLUSION

The application of suture anchor internal fixation in the treatment of RHFs has the advantages of accurate reduction, no need for a secondary operation to remove the fixation materials, less trauma, fewer complications, good fracture healing, and good recovery of elbow extension, flexion, and rotation functions.

Radial head arthroplasty: a descriptive study of 970 patients in an integrated health care system

BACKGROUND

Radial head arthroplasty (RHA) is commonly performed for isolated comminuted radial head fractures and in conjunction with traumatic elbow instability. However, there is a paucity of literature directly describing the characteristics and outcomes of patients who undergo RHA in a community-based setting. We describe a cohort of 970 RHA performed in the California regions of a US integrated health care system over a 9-year period. Patient demographics, implant selection, 90-day acute postoperative events, and cumulative reoperation/revision rates are included.

METHODS

Patients aged ≥18 years who underwent primary RHA were identified (2009-2017). Patient characteristics and demographics, including age, body mass index, gender, diabetes status, American Society of Anesthesiologists (ASA) classification, primary diagnosis, and concomitant procedures were described. Crude cumulative revision and reoperation probabilities were calculated as 1 minus the Kaplan-Meier estimator, with follow-up time calculated as the time from the index RHA to revision/reoperation date for those with the outcome of interest and time from index RHA to censoring date (eg, date of death, health care termination, study end date [March 31, 2018]) for those without the outcome. Ninety-day postoperative incidence of emergency department (ED) visit, readmission, and mortality was calculated as the number of patients with the event of interest over the number of patients at risk.

RESULTS

A total of 970 patients underwent primary unilateral RHA by 205 surgeons during the study period. Annual procedure volume increased from 53 procedures in 2009 to 157 procedures in 2017. More patients were female, without diabetes, and had an ASA classification of 1 or 2. Fracture was the predominant indication for RHA (98.4%) and more than half (54.3%) had concomitant procedures performed. Most implants were press fit (63.2%) over loose fit, and >90% were monopolar. Three-year cumulative revision and reoperation probabilities following RHA were 6.5% (95% confidence interval [CI] = 5.0%-8.5%) and 8.2% (95% CI = 6.5%-10.3%), respectively. Revisions and reoperations tended to occur within the first postoperative year. Of the 970 RHA patients, 83 (8.5%) had a 90-day ED visit, 58 (6.0%) had a 90-day readmission, and 1 (0.1%) died within a 90-day postoperative period.

CONCLUSION

This large cohort of RHA patients provides information about the practice of RHA at large and in the community. Surgeons are performing more RHA over time and choosing press fit stems more often. Revisions and reoperations tended to occur early. Readmission and ED visits were low but not negligible, with pain being the most common reason for ED visit.

Long-term outcomes of open arthrolysis combined with radial head arthroplasty for post-traumatic elbow stiffness: results are durable over 8 years

BACKGROUND

Post-trauma elbow stiffness (PTES) is a common complication after elbow trauma that causes severe upper limb disability. Open elbow arthrolysis (OEA) with radial head arthroplasty (RHA) is an effective method to treat PTES with rotation limitation, or persistent pain/instability after radial head resection. However, no long-term results have been reported for this technique. This study aimed to show the clinical and radiographic outcomes of OEA with RHA over 8 years and compare its efficacy at 3 years (short-term).

METHODS

Patients with PTES treated by OEA with RHA between September 2010 and December 2012 were retrospectively reviewed. Seventeen patients were followed up over 8 years (range, 100-106 months). A bipolar prosthesis of RHA was performed during OEA. Preoperative, 3-year, and 8-year elbow and forearm motion, upper limb function, radiographic outcomes, and complications were recorded.

RESULTS

Clinically important improvements in elbow motion and forearm rotation were obtained, from 34° and 58° preoperatively, to 109° and 135° at 3 years, which were maintained over 8 years, to 113° (P = .262) and 134° (P = .489). The Mayo Elbow Performance Index had clinically important increases from the preoperative level of 58 to 94 points at 3 years, and was maintained over 8 years (95 points, P = .422), with 100% reporting excellent to good outcomes. Pain and nerve symptoms were also improved. Complications consisted of new-onset ulnar nerve symptoms in 1 patient, nonclinically significant heterotopic ossification recurrence in 3, humeroulnar arthritis exacerbation in 4, and periprosthetic lucency in 8.

CONCLUSIONS

OEA with RHA yielded satisfactory short-term outcomes for PTES at 3 years, with substantial improvements in elbow mobility and function, and the results were durable over the long term (8 years).

The serious full-length forearm injury - a case report and literature review

Background

Among upper limb injuries, carpal bone fractures and dislocation, Essex-Lopresti injury, and the terrible triad injury of the elbow are serious and relatively rare injuries. These injuries require surgical intervention. The surgical method is difficult, and the treatment effect is poor. These injuries have not been described in the same limb in the literature.

Case presentation

A 21-year-old male patient fell from a height in our institution and sustained multiple injuries, including carpal bone fracture-dislocation, Essex-Lopresti injury, and the terrible triad injury of the elbow of his right upper limb. After 2 surgeries and rehabilitation, he returned to work. We reviewed available reviews and related literature on serious upper-limb damage.

Conclusions

Full-length forearm injury is very rarely encountered, and the management of such fractures is difficult. Radial head replacement with a metal prosthesis, reconstructed the IOM with Tightrope, and fixed the DRUJ with a K-wire pin is appropriate treatment.

Double ulnar osteomy for the treatment of congenital radial head dislocation

OBJECTIVE

The aim of this study was to retrospectively evaluate the effects of our double osteotomy technique in the treatment of congenital radial head dislocation (CRHD).

METHODS

A total 14 children (14 elbows; 71.42% male; mean age: 9.31 ± 3.06 years) with CRHD who underwent double osteotomy of the proximal ulna between April 2010 and June 2015 were included in the study. The patients with CRHD were identified according to medical history, plain radiographs or magnetic resonance imagings. The outcomes were evaluated through comparison of the preoperative and postoperative motion range of elbow and Mayo Elbow Performance Score (MEPS).

RESULTS

After a follow-up of 13-35 months (22.29 ± 5.80), compared with pre-operation, the flexion (132.14 ± 3.23° vs 123.21 ± 7.75°, P = 0.003), extension (8.21 ± 4.21° vs 1.07 ± 3.50°, P = 0.003), and pronation of elbow (83.21 ± 4.21° vs 80.36 ± 4.14°, P = 0.011) improved significantly in all patients. Furthermore, the carrying angle was recovered to the normal level (5-15°) in all of these patients (18.57 ± 5.69° vs 8.21 ± 2.49°, P = 0.001). MEPS score was significantly increased postoperatively (96.79 ± 2.49 vs. 90.71 ± 1.82, P = 0.000), with the good outcome in CRHD patients.

CONCLUSION

The results of our study suggested that this double osteotomy on the proximal ulna might be an effective method for the treatment of CRHD.

LEVEL OF EVIDENCE

Level IV, Therapeutic Study.

Radial Head Replacement Through a Kocher Approach

PURPOSE

Radial head fractures are some of the most common elbow fractures. Fractures with 3 or more fracture fragments have been shown to have worse outcomes when treated with open reduction and internal fixation (ORIF). Radial head replacement offers an alternative treatment for those more comminuted radial head fractures.

METHODS

Three-part radial head fractures make anatomical reduction more difficult to obtain with ORIF. Radial head fractures requiring replacement have shown good clinical outcomes. As a result, radial head arthroplasty offers a good treatment option for 3-or-more-part radial head fractures.

RESULTS

This video presents a case of a radial head arthroplasty for a 3-part radial head fracture in a 23-year-old man. The radial head implant provides a smooth and concentric surface for articulation with the capitellum while providing stability to the elbow.

CONCLUSIONS

Radial head replacement provides a good alternative to ORIF, producing similar elbow range of motion and providing good stability compared with the contralateral elbow.

Replacement or repair of terrible triad of the elbow: A systematic review and meta-analysis

BACKGROUND

Surgical treatment for terrible triad injuries remains a challenging clinical problem, and controversy exists of whether it is better to repair or replace the radial head. The objective of this systematic review was to evaluate the clinical outcomes of repair and arthroplasty replacement of the radial head in patients with terrible triad injury.

METHODS

Medline, Cochrane Library, EMBASE, and Google Scholar were searched up to July 30, 2018 to identify the relevant studies, which included patients who had received treatments of the terrible triad of the elbow and also had reported with the quantitative outcomes. Outcomes of interest were functional outcomes.

RESULTS

Four studies with a total of 115 patients were included in the systematic review. Most patients were type II or III radial head fractures based on the Mason classification systems. Fifty-one patients received radial head repair surgery and 64 underwent replacement. Two studies had indicated that patients in the replacement group were significantly associated with better treatment outcome assessed by DASH (Disabilities of the Arm, Shoulder and Hand) and MEPS (Mayo Elbow Performance Score) scores. The meta-analysis indicated that patients with the arthroplasty replacement were associated with significantly better ROM outcomes in flexion, extension, pronation than those with radial head repaired. In addition, patients in the replacement group showed fewer post-surgery complications than those in the repair group.

CONCLUSIONS

Our review had indicated that patients with terrible triad injuries undergo arthroplasty replacement have better clinical outcomes and fewer post-surgery complications than those received the repair surgery. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow.

Treatment of Radial Head Fractures and Need for Revision Procedures at 1 and 2 Years

PURPOSE

Optimal treatment strategies for radial head fractures remain a subject of debate. We examined national practice patterns in the management of radial head fractures to determine rates of surgical treatment, type of surgery employed, and the incidence of reoperation.

METHODS

Between 2007 and 2011, we identified patients with radial head fractures along with their associated injuries by International Classification of Diseases, Ninth Revision codes in a national database of orthopedic insurance records. For those who underwent surgery, the type of intervention was identified and each patient was observed to determine whether a subsequent procedure was needed by 1 and 2 years. Chi-square analysis was performed to make comparisons between groups.

RESULTS

A total of 58,404 radial head fractures were identified between 2007 and 2011; of these, 2,981 underwent surgical treatment (5.1%). Rates of surgical intervention were significantly higher in the context of associated injuries. Among the 2,981 radial head fractures treated surgically, 57.1% underwent open reduction internal fixation (ORIF), 37.9% were treated with radial head arthroplasty, and 4.9% underwent radial head excision. When the surgically treated radial head fracture was associated with a coronoid fracture, elbow dislocation, or proximal ulna fracture, 64.2%, 54.3%, and 47.2% were treated with arthroplasty, respectively, compared with 32.6%, 41.9%, and 52.6% treated with ORIF, respectively. After initial surgical treatment, 12.7% and 14.4% of radial head fractures that underwent ORIF required a secondary surgery at 1 and 2 years, respectively, compared with 8.6% and 10.7% of radial head arthroplasties and 8.3% and 8.4% of resections.

CONCLUSIONS

Rates of arthroplasty were significantly higher in the context of associated injury, particularly in the setting of a coronoid fracture or elbow dislocation. Fractures initially treated with ORIF had a higher rate of revision surgery at both 1 and 2 years after the index procedure compared with arthroplasty.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Results after radial head arthroplasty in unstable fractures

BACKGROUND

Whereas most radial head fractures are stable injuries, they sometimes occur as part of complex injury patterns with associated elbow instability. Radial head arthroplasty has been favored in patients with unreconstructable radial head fractures and unstable elbow injuries. The purpose of this study was to review radiographic outcomes, functional outcomes, and complications after radial head arthroplasty for radial head fracture in unstable elbow injuries.

METHODS

This study was a retrospective review of radial head fractures treated with radial head arthroplasty by a single surgeon during a 15-year period. Demographics of the patients, injury details, operative reports, radiographic and clinical outcomes, and any complications were recorded. Patients were divided into stable and unstable elbow injury groups.

RESULTS

A total of 68 patients were included. There were 50 unstable fractures that were compared with 18 stable fractures. Patients with unstable radial head fractures with associated elbow dislocation achieved mean flexion and mean forearm rotational arc of motion similar to that of patients with stable radial head fractures. However, supination loss was greater in the unstable group than in the stable fracture group, with a mean difference of 10°. Radiographic outcomes and complication rates did not differ between injury groups. There was no observed decrease in implant longevity in patients with unstable elbow injuries.

CONCLUSIONS

Radial head arthroplasty is an effective option for treatment of unstable elbow injuries, with recovery of functional elbow range of motion and no difference in complication rate or implant survivorship compared with those patients with stable injuries.

Screw fixation versus arthroplasty versus plate fixation for 3-part radial head fractures

PURPOSE

To compare the outcome following headless compression screw fixation versus radial head arthroplasty versus plate fixation for 3-part Mason types III or IV radial head fracture.

METHODS

Records of 25 men and 16 women aged 21 to 80 (mean, 43.3) years who underwent fixation using 2 to 3 2-mm cannulated headless compression screws (n=16), radial head arthroplasty (n=13), or fixation with a 2-mm Synthes plate (n=12) for 3-part Mason types III or IV radial head and neck fracture were reviewed. Treatment option was decided by the surgeon based on the presence of associated injury, neurovascular deficit, and the Mason classification. Bone union, callus formation, and complications (such as heterotopic ossification, malunion, and nonunion) were assessed by an independent registrar or consultant using radiographs. The Mayo Elbow Performance Score and range of motion were assessed by an independent physiotherapist.

RESULTS

The median age of the 3 groups were comparable. Associated injuries were most common in patients with arthroplasty, followed by screw fixation and plate fixation (61.5% vs. 50% vs. 33%, p=0.54). The median time to bone union was shorter after screw fixation than plate fixation (55 vs. 86 days, p=0.05). No patient with screw fixation had nonunion, but 4 patients with plate fixation had nonunion. The 3 groups were comparable in terms of the mean Mayo Elbow Performance Score (p=0.56) and the mean range of motion (p=0.45). The complication rate was highest after plate fixation, followed by screw fixation and arthroplasty (50% vs. 18.8% vs. 15.4%, p=0.048). Excluding 20 patients with associated injuries (8 in screw fixation, 8 in arthroplasty, and 4 in plate fixation), the 3 groups were comparable in terms of the median time to bone union (p=0.109), mean Mayo Elbow Performance Score (p=0.260), mean range of motion (p=0.162), and complication rate (p=0.096).

CONCLUSION

Headless compression screw fixation is a viable option for 3-part radial head fracture. It achieves earlier bone union with fewer complications.