Comminuted fractures of the radial head: resection or prosthesis?

Operative treatment of Mason Type III radial head fractures - A comparative analysis using PROMIS

Objectives

The purpose of this study is to evaluate the outcomes of operatively treated Mason Type III radial head fractures. Additionally, this project seeks to assess efficacy of PROMIS in evaluating post-operative outcomes for this patient population.

Methods

A total of 143 patients who underwent operative treated Mason Type III radial head fractures were analyzed retrospectively. PROMIS physical function (PF), PROMIS upper extremity (UE), PROMIS pain interference (PI), demographic variables, and range of motion were collected and analyzed over 12-month follow-up.

Results

Radial head arthroplasty (RHA) was performed on 89 patients, open reduction and internal fixation (ORIF) was performed on 47 patients, and radial head excision was performed on 7 patients. Among the RHA patients, PROMIS PF, PI and UE demonstrated a change of -1.33 (p < 0.05), -1.48 (p < 0.05), and 2.23 (p < 0.05) respectively from injury to 12-months. Among the ORIF patients, PROMIS PF, PI and UE demonstrated a change of 3.22 (p < 0.05), -1.56 (p < 0.05), and 2.09 (p < 0.05) respectively from injury to 12-months. At the pre-operative and 12-month visits, the RHA group demonstrated lower PROMIS PF scores 34.75 vs 38.02 (p < 0.05) and 33.42 vs 41.24 (p < 0.05) respectively. Ther was no difference in PROMIS PI, UE, or elbow range of motion between the two groups at 6- or 12-month follow-up (p > 0.05).

Conclusion

Comparing the RHA and ORIF groups, there was no difference in PROMIS PI or UE scores nor was there a clinically significant improvement at the 6- or 12-month mark. The ORIF group demonstrated improved PROMIS PF at all follow-up periods and did show a clinically significant improvement. Patient Acceptable Symptom State (PASS) correlated only with PROMIS UE at 6- and 12- months for both groups.

Prognostic Factors of Function in Nonoperatively Treated Radial Head Fractures: A Prospective Cohort Study

OBJECTIVES

To identify patient-related factors and fracture characteristics influencing the functional outcomes of nonoperatively treated radial head fractures and to determine function at 1 year.

DESIGN

Prospective cohort study.

SETTING

Academic Level 1 trauma center.

PATIENTS/PARTICIPANTS

Consecutive isolated radial head fractures fitting the inclusion criteria between May 2013 and July 2016.

INTERVENTION

Nonoperative treatment of isolated radial head fractures.

OUTCOME MEASUREMENTS

Logistic regressions between potential prognostic factors and function assessed with the Mayo Elbow Performance Score (MEPS), the Disabilities of the Arm, Shoulder, and Hand (DASH) score, and range of motion at 1.5-3-6-12 months.

RESULTS

One hundred fourteen patients were included (78% Mason I [OTA/AO 2R1B1], 20% Mason II [OTA/AO 2R1B3], and 2% Mason III [OTA/AO 2R1C3]). Mean MEPS and DASH score at the last follow-up were excellent [96.4 ± 7.6 and 3.7 ± 8.6] with, respectively, 79.8% and 92.7% of satisfactory results. Depressive symptoms at injury baseline (Quick Inventory of Depressive Symptomatology > 5) are a constant predictor of unsatisfactory function (MEPS <90 or DASH >17]). Older age and female sex were all linked to worse function at the first follow-ups ( P < 0.05), whereas lower socioeconomic class and receiving financial compensations were associated to unsatisfactory function at 1 year ( P < 0.05).

CONCLUSIONS

Although most nonoperatively treated radial head fractures heal with excellent function, some patients still exhibit unsatisfactory results at 1 year. Symptoms of depression at injury baseline are a constant and significant predictor of unsatisfactory function. Early detection of depressive symptoms would allow for interventions that may optimize function.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Mid-term outcome following radial head arthroplasty in acute trauma: risk factors for poor outcome

BACKGROUND

The aims of this study were to evaluate the outcomes of a single type of radial head implant in a large cohort of patients at mid-term follow-up and to determine the associated risk factors for inferior functional outcomes.

METHODS

We performed a retrospective follow-up assessment of 65 patients (33 women and 32 men; mean age, 53.3 years [range, 22-81 years]) who underwent radial head arthroplasty (RHA) for acute trauma between 2012 and 2018, after a minimum follow-up period of 3 years. The Mayo Elbow Performance Score, Oxford Elbow Score, Disabilities of the Arm, Shoulder and Hand score, and Mayo Modified Wrist Score were evaluated, and all available radiographs were analyzed. All complications and revision procedures were assessed. Bivariate and multivariate regression analyses were performed to identify potential risk factors for a poor outcome following RHA.

RESULTS

After an average follow-up period of 4.1 years (range, 3-9.4 years), the mean Mayo Elbow Performance Score was 77.2 (standard deviation [SD], 18.9); mean Oxford Elbow Score, 32.0 (SD, 10.6); mean Mayo Modified Wrist Score, 74.6 (SD, 13.7); and mean Disabilities of the Arm, Shoulder and Hand score, 29.0 (SD, 21.2). Average range of motion measured 10° (SD, 15°) in extension, 125° (SD, 14°) in flexion, 81° (SD, 14°) in pronation, and 63° (SD, 24°) in supination. The overall complication and reoperation rates were 38.5% and 30.8%, respectively, with severe elbow stiffness being the most common reason for revision. Patient age >50 years, the use of an external fixator, the presence of accompanying medial collateral ligament injuries, and the development of higher-grade osteoarthritis were associated with a poor outcome.

CONCLUSION

Satisfactory medium-term outcomes can be achieved using a monopolar, long-stemmed RHA in patients with acute trauma. However, complication and revision rates are high, frequently leading to inferior outcome scores. Additionally, a higher patient age, the use of an external fixator, the presence of accompanying medial collateral ligament injuries, and the occurrence of higher-grade osteoarthritis were associated with a poor outcome; these factors should raise awareness by the treating trauma surgeon.

Mason type III fractures of the radial head: ORIF, resection or prosthetic replacement?

PURPOSE

This study focused on a comparison of mid-term clinical, functional and radiographic outcomes of adults treated by open reduction and internal fixation (ORIF), radial head prosthesis (RHP) and resection (RHR).

METHODS

The retrospective evaluation concerned 47 surgically treated patients after a mean follow-up of 53 months. All patients were grouped according to the surgical procedure performed: 15 in the RHP group, 16 in the ORIF group and 16 in the RHR group. At the follow-up, outcome assessment was based on radiographs, range of motion (ROM) and functional rating scores.

RESULTS

Patients treated by RHR had significantly higher mean age and shorter operation time than other two groups. Compared to ROM, flexion, extension and pronation were significantly worse in patients treated by ORIF than those in the RHP group and the RHR group. Supination was significantly better in the RHP group. However, no statistical differences were observed in functional rating scores among the three groups. Regarding complications, instability was the only cause of revision surgery in the RHP group and the RHR group. On the other hand, the ORIF group revision rate was 50% and secondary displacement was the most frequent cause of failure.

CONCLUSION

The ORIF group did not show good results with greater elbow stiffness and higher revision rate than the other two techniques. RHR may be suitable for elderly patients with lower functional demands as it reported good clinical results and reduced operation time.

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.

Clinical and radiological outcome of Mason-Johnston types III and IV radial head fractures treated by an on-table reconstruction

Background

Only few methods treating comminuted radial head fractures have been established providing sufficient joint reconstruction, restoring radial length and enabling early joint mobilization. When an anatomical reconstruction using open reduction and internal fixation is not possible, radial head resection or primary arthroplasty is often conducted. An “Ex situ/on-table” reconstruction is widely disregarded but can be an option. The purpose of this study was to evaluate the functional and radiological outcome of comminuted radial head fractures treated with an “on-table” reconstruction and internal fixation using a low profile plate.

Methods

Fourteen patients who sustained a radial head fracture (9 Mason-Johnston type III and 5 Mason-Johnston type IV) and were treated with an “on-table” reconstruction between 2010 and 2020 were evaluated retrospectively. The patients mean age was 41.3 years (range 21–69). The clinical evaluation included active range of motion, grip strength, pain level and elbow stability. The functional outcome was assessed using the Disability of Arm, Shoulder and the Hand (DASH) score, Mayo Elbow Performance Index (MEPI), Broberg and Morrey score. The radiological examination included a.p. and lateral views of the injured elbow to evaluate nonunions, loss of reduction, joint alignment, avascular radial head necrosis, heterotopic ossifications and posttraumatic osteoarthritis.

Results

The inclusion rate was 74% with a mean follow-up of 50 months (range 16–128). The mean elbow flexion of the injured side was 126° (range110–145°) with an average extension loss of 8° (range 0–40°). Pronation was 65° (15–90°) and supination 66° (5–90°). The mean MEPI was 87 points (range 45–100). The mean DASH score was 13 points (range 1–88). According to the Broberg and Morrey functional scoring system, the average score was 92 points (range 88–100). Complete bone union was achieved in 9 cases, partial union in 4 cases and nonunion in one case. There were no signs of avascular necrosis of the radial head. Signs of post-traumatic osteoarthritis were seen in 11 cases. Five patients needed an implant removal due to a radio-ulnar impingement and one patient a revision surgery due to the nonunion and implant breakage.

Conclusions

An on-table (ex situ) reconstruction of the radial head is a reliable option with a good clinical outcome and low complication rate in the surgical treatment of comminuted radial head fractures. It can restore joint alignment and maintain radial length. The risk for avascular necrosis is neglectable, and the bone healing rate is high.

Excision Versus Replacement in Unrepairable Comminuted Fractures of the Radial Head: A Systematic Review of Outcomes and Complications

BACKGROUND

The radial head fractures comprise approximately 4% of all fractures around the elbow. The outcomes of open reduction and internal fixation are poor in fractures with more than three fragments, and the excision of radial head is considered a viable surgical treatment option. However, it is associated with its own set of complications. The radial head prosthetic replacement has emerged as an alternative in management of these fractures with constraints of cost and related complications. Hence, the treatment for the unrepairable comminuted radial head fractures still remains controversial.

AIMS AND OBJECTIVES

This systematic review and meta-analysis was conducted to compare the post-operative outcomes of the radial head excision versus prosthetic replacement in comminuted Mason type-III fractures of radial head.

METHODOLOGY

Three databases of Medline (PubMed), Scopus, and Embase were searched for comparative studies on the study question and relevant studies which mentioned at least one of the outcomes of interest (functional outcome scores and number of complications) were included.

RESULTS

Six studies were part of this review with 82 excisions and 99 prosthetic replacements. There was no significant difference between the two groups in terms of number of complications (OR 0.65; 0.08-5.07); and measures of functional outcomes; Mayo elbow performance score or MEPS (mean difference - 6.56; - 23.45 to 10.33). The incidence of elbow osteoarthritis, heterotrophic ossification, stiffness, and instability were similar in both groups. The flexion extension arc in degrees was better in excision group (mean difference 9.93; 1.31-18.55; p = .02).

CONCLUSION

Excision is a reasonable surgical option for isolated comminuted radial head fractures with similar results of function and associated rates of complications as prosthetic replacements. The arc of motion is also better with excisions. There have been reports of more osteoarthritis with excision and arthroplasty has been advised in younger patients; however, we had no quantitative proof of that in this review.

Clinical and radiological outcomes of autologous humeral bone grafting for radial head reconstruction: a minimum 2-year follow-up

PURPOSE

The aim of this prospective study was to assess the clinical and functional results of radial head reconstruction with an autologous bone graft from distal humerus in 12 patients, with a follow-up for a period of 24 months.

METHODS

From March 2017 to June 2018, we surgically treated 12 patients using an autologous bone graft from the lateral distal metaphysis of the homolateral humerus. Patients were divided into two groups: -Group A consisted of patients with previous failed ORIF for radial head fracture. Patients underwent revision surgery at an average time of 7 months (between 6 to 8 months) from the first surgery. All the patients reported pain during the elbow range of motion with no gross clinical signs or instability of the joint. They all presented standard X-ray and CT-scan of the elbow suggestive of non-union fracture. None of them presented osteoarthritic modification at the time of surgery. -Group B consisted of patients reporting acute irreparable radial head fractures. Patients were evaluated clinically at 6-, 12-, and 24-months duration according to Disabilities of the Arm. Shoulder and Hand (DASH), Mayo Elbow Performance Score (MEPS), and Visual analogue score for pain (VAS);, range of motion (ROM) was evaluated at 6 and 24 months after surgery. Plain radiographs on anteroposterior and lateral views of the elbow were evaluated at final follow-up.

RESULTS

In both, groups (A and B) patients showed a significant improvement with regards to VAS, MEPS, and DASH at each follow-up (p < 0.05). X-rays showed complete bone healing in all patients with no sign of mobilisation or loosening of the screws. One case in group A presented asymptomatic partial ossification of LUCL. No cases of fracture or residual pain at the donor site. Furthermore, no other complications such as infection, wound issues, elbow instability, elbow stiffness, ulnar neuritis, graft non-union were reported.

CONCLUSIONS

Distal humerus bone graft should be considered a reliable option for the treatment of acute fractures that are unrepairable fractures or revision surgery for failed ORIF of the radial head, especially among young patients where prosthesis may be reserved as a salvage procedure, and radial head resection is a damaging and is not considered desirable.

LEVEL OF EVIDENCE

Level IV - Prospective Case Series.

Clinical outcomes after internal fixation, arthroplasty and resection for treatment of comminuted radial head fractures: a systematic review and network meta-analysis

BACKGROUND

Radial head fractures make up approximately 3% of all fractures, and they are the most common elbow fracture in adults. The treatment for comminuted radial head fracture remains controversial. This systematic review was conducted with the aim to compare postoperative outcomes among surgical treatments to identify which method is the best for comminuted radial head fractures.

METHODS

Relevant studies were identified from Medline and Scopus from inception to February 22, 2020, that reported Mayo Elbow Performance Index (MEPI) score and postoperative complications of either treatment. A network meta-analysis was applied to assess treatment outcomes. Probability of being the best treatment was estimated using surface under the cumulative ranking curves (SUCRA).

RESULTS

Twelve comparative studies and one randomized controlled trial (N = 526 patients) met the inclusion criteria. Interventions included open reduction and internal fixation (ORIF) (N = 210 patient), radial head arthroplasty (RHA) (N = 227 patients) and radial head resection (RHR) (N = 152 patients). A network meta-analysis showed that the MEPI of RHA was significantly higher when compared to ORIF and RHR, with a pooled mean MEPI of 7.28 (1.69, 12.86) and - 7.32 (- 13.21, - 1.43), respectively. In terms of complications, RHA and RHR had lower risk with RRs of 0.61 (0.29, 1.31) and 0.54 (0.24, 1.25) when compared to ORIF. The SUCRA probabilities of RHA and RHR were in the first rank with 99.2% in MEPI and 60.6% in complications, respectively.

CONCLUSIONS

This study suggests that RHA is the best treatment of choice for efficacy and safety in the treatment of comminuted radial head fracture, while RHR is the safest choice to minimize postoperative complications and enable patients to perform all daily life activities.

Chronic isolated radial head dislocation in adults: Technical note and literature review

Isolated traumatic radial head dislocation is exceedingly rare in adults, usually diagnosed on an emergency basis, and reduced by external manoeuvres. If the diagnosis is not made immediately, external reduction is no longer feasible. Various options have been described for treating these chronic forms, including therapeutic abstention, radial head resection and annular ligamentoplasty combined, if appropriate, with osteotomy of the ulna. In patients with incapacitating symptoms, proposing a surgical option makes sense. Here, we describe the technique developed by PM Grammont, which combines ligamentoplasty and an oblique flat osteotomy of the ulna. We used this technique in a 31-year-old male with isolated anterior dislocation of the radial head of 3 months' duration. One year after surgery, he had fully recovered range of motion in all planes. He returned to work 5 months after surgery. The promising clinical and radiological outcomes in our patient support the use of this technique in adults with chronic isolated radial head dislocation. LEVEL OF EVIDENCE: IV.

Outcomes of press-fit radial head arthroplasty following complex radial head fractures

INTRODUCTION

Press-fit radial head arthroplasty (RHA) is increasingly popular in treating complex radial head fractures. This study assessed the outcome of RHA, including the outcome following re-operation, and explored potentially influencing factors.

HYPOTHESIS

Complex radial head fractures treated with press-fit radial head prosthesis would have a favourable outcome.

MATERIAL AND METHODS

Data on all consecutive patients treated with anatomic press-fit RHA from February 2002 to February 2015 were analysed. Post-surgery clinical and X-rays assessments included a post-discharge evaluation of function. Standardised methods implemented include the assessment of range of motion (ROM), the Mayo Elbow Performance Score (MEPS) and subjective satisfaction scales.

RESULTS

Forty-five patients were recruited and 71% were classified in Mason IV and 62.2% had the "terrible triad". Re-operation was performed in 26.7% and prosthesis removal in 15.6%. Mean follow-up was 140.8 months (95% CI 117.7-164) and prosthesis survival was 69.5% at 24 months. Mean MEPS before re-operations was 86.3±15.9. Pain and/or instability were the most common reasons for re-operation, and re-operations were significantly more frequent in patients having one or more "associated injuries" (p=0.05), but not the terrible triad; and in patients with radiological "loosening" signs (p<0.01). Subjective scores were relatively good in most patients, although the functionality perceived in the re-operation with implant removal group was rather low.

DISCUSSION

Several studies of complex radial head fractures treated with press-fit radial head prosthesis have also shown favourable results, but the patients in such studies generally had less severe lesions. Moreover, differently from previous reports, this study with a long follow-up has included a younger population with high functionality requirements. Pain and/or instability, as observed in several previous reports, were the most common reasons for re-operation, but contrary to the expectation, the terrible triad was not associated with unfavourable outcome.

CONCLUSION

Treatment of complex fractures with press-fit radial head prosthesis, including re-operation with implant removal yields satisfactory results. Most scores of functional and subjective outcome improved following the re-intervention and most patients returned to their usual occupation.

LEVEL OF EVIDENCE

Level IV; case series; treatment study.

Radial head excision and Achilles allograft interposition arthroplasty for the treatment of chronic pediatric radiocapitellar pathologies: A report of four cases

BACKGROUND

Severe radiocapitellar pathologies represent a unique problem in the pediatric population, as radial head excision can lead to substantial long-term complications. We present a case series of four pediatric patients treated by a novel technique-radial head excision followed by Achilles allograft interposition arthroplasty.

METHODS

Four children (ages 12-15 years) are described. Their clinical and radiographic outcomes were assessed by a visual analog scale, the Mayo Elbow Performance Score, the Disabilities of the Arm, Shoulder and Hand questionnaire, grip strength, and range of motion.

RESULTS

At a mean follow-up of two years, the average flexion-extension arc of motion improved from 107° to 131°, and the rotation arc improved from 100° to 154°. The average visual analog scale, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand scores were 2, 92.5, and 11.5, respectively. Two patients required subsequent additional procedures-manipulation under anesthesia and ulnar shortening osteotomy. Proximal migration of the radius was observed in three out of the four patients.

DISCUSSION

Combined radial head excision and Achilles allograft interposition arthroplasty represents a viable option for the treatment of chronic pediatric radiocapitellar pathologies, with good results in terms of clinical and functional outcomes as well as patient satisfaction in the short-medium term.

Heterotopic Ossification After Elbow Fractures

Heterotopic ossification (HO), a complication after surgical repair of elbow fractures, can result in pain, decreased range of motion, or complete ankylosis of the joint. This updated systematic review focused on compiling incidence and prevalence rates of HO after surgical repair of various types of elbow fractures. The overall incidence of HO after surgical repair was calculated to be 28.7%, a result comparable with rates in the literature. Further analysis suggested that the odds of having HO may be less after distal humerus fractures than after proximal radius fractures, terrible triad injuries, and elbow fractures/dislocations. [Orthopedics. 2021;44(1):10-16.].

Retrospective cohort study on radial head arthroplasty comparing long-term outcomes between valgus type injury and fracture dislocation

Background

Radial head arthroplasty (RHA) has been commonly adopted for irreparable radial head fractures while little information is addressed on valgus type injury. The purpose of this study is to report long-term outcomes and radiographic analysis in RHA for valgus type injury with comparison to fracture dislocation injury.

Methods

A retrospective cohort study was conducted in patients receiving unilateral RHA with loose-fit, modular metal prosthesis for irreparable radial head fractures between 2004 and 2012. Totally, 33 patients with a mean follow up of 9 years (range, 7 to 15 years) were enrolled and divided into two groups including 14 valgus injuries and 19 fracture-dislocations. Demographics of the patients, injury details, clinical and radiographic outcomes, and correlation analysis were investigated and compared between two groups.

Results

In patient demographics, significant difference was noted in sex distribution (p = 0.001), lateral collateral ligament involvement (p = 0.000) and time from injury to RHA (p = 0.031) between two groups. No patient underwent subsequent removal or revision of prosthesis. Good to excellent results according to Mayo Elbow Performance Score (MEPS) was achieved in 13 and 14 patients in group A and B respectively. Final motion range and Disabilities of the Arm, Shoulder, and Hand score was significantly better in valgus injury group. Radiographic analysis demonstrated fewer patients in valgus injury group presented periprosthetic osteolysis with weak to moderate negative correlation between radiolucency score and MEPS.

Conclusions

With an average of 9 years follow-up, RHA using loose-fit, modular metal prosthesis achieves encouraging outcomes for both valgus injury and fracture dislocation. In valgus type injury, better motion range, lower disability score and lower incidence of periprosthetic osteolysis is noted while correlation analysis of radiolucency score suggests extended, long-term investigation.

Management of the failed radial head arthroplasty

Primary radial head arthroplasty (RHA) produces good or excellent results in approximately 85% of patients. However, complications are not uncommon and have been described in up to 23% of cases.

The number of RHA is increasing, and consequently the absolute number of complications is expected to rise as well. The decision on whether to revise or remove the prosthesis seems more likely to depend on the preference of the surgeon or the hospital, rather than on objectifying problems with the prosthesis.

The current article presents an algorithm for the work-up and treatment of most complications that can occur following RHA.

Five subgroups of problems were identified: osteoarthritis, stiffness, instability, infection and implant-related issues.

In short, the preferred treatment depends mainly on the chondral condition and stability of the elbow joint.

Cite this article: EFORT Open Rev 2020;5:398-407. DOI: 10.1302/2058-5241.5.190055

Neurologic complications after surgical management of complex elbow trauma requiring radial head replacement

BACKGROUND

Radial head arthroplasty (RHA) has become a successful procedure for addressing acute unreconstructible radial head fractures that compromise elbow stability in complex elbow trauma. The purpose of this study was to investigate the incidence of and risk factors for the development of neurologic complications after surgical treatment of complex elbow fractures that require an RHA.

METHODS

Sixty-two patients with an unreconstructible radial head fracture and complex elbow instability treated with RHA were included. There were 33 men and 29 women, with a mean age of 54 years (range, 22-87 years). The average follow-up period was 5.2 years (range, 3-16 years). All patients were neurologically intact before surgery. The arthroplasty was implanted through a Kocher approach in 55 cases, whereas a Kaplan approach was used in 7. An uncemented smooth stem arthroplasty (Evolve) was used in 27 patients, and an anatomic ingrowth system (Anatomic Radial Head), in 35. At the time of surgery, 23 patients underwent fixation of a coronoid fracture and 15 underwent plating of the proximal ulna. All patients were clinically examined immediately after surgery and during follow-up to detect any degree of neurologic deficit. Radial and ulnar nerve injuries were classified according to the Hirachi and McGowan classifications, respectively. Functional outcomes were evaluated with the Mayo Elbow Performance Score.

RESULTS

A complete posterior interosseous nerve palsy occurred postoperatively in 2 patients. Hand function had completely recovered in both at 2 months after surgery without sequelae. Nine patients complained of ulnar nerve symptoms (immediately after surgery in 6 and as delayed ulnar neuropathy in 3). Most patients with ulnar nerve deficits had undergone additional surgical procedures to address ulnar fractures. Among patients with ulnar neuropathies, only 3 complained of mild sensory symptoms at the latest follow-up. No significant differences in range of motion and Mayo Elbow Performance Score were found between patients with and without neurologic complications. Associated olecranon or coronoid fixation and a prolonged tourniquet time were identified as risk factors for neurologic complications.

CONCLUSION

This study shows that the incidence of neurologic complications associated with the surgical treatment of complex elbow fractures requiring implantation of a radial head prosthesis may be underestimated in the literature. Inappropriate retraction in the anterior aspect of the radial neck, a prolonged ischemia time, and concomitant coronoid or olecranon fracture fixation represent the main risk factors for the development of this complication. Although the great majority of patients have full recovery of their nerve function, they should be advised on the risk of this stressful complication.

Radial Head Arthroplasty, Excision and Osteosynthesis in Complex Elbow Fracture-Dislocations in Young Adults: What is Preferred?

OBJECTIVE

Complex elbow fractures are common injuries in young adults. Results in recent studies with various operative treatment protocols are equivocal. We compared the results of radial head arthroplasty, excision with osteosynthesis in such injuries at two follow-ups 1 year apart.

METHODS

Thirty-five patients of complex elbow fracture-dislocations including, posterior/anterior olecranon dislocation of elbow, terrible triad injury, anteromedial facet of coronoid fracture, Type IV Monteggia fracture-dislocation and unclassified elbow dislocation were enrolled. They were managed operatively by standardized protocol similar to McKee et al. radial head reconstruction with miniplates, lag screws or non-operative treatment for undisplaced fractures. Arthroplasty of radial head with cemented prosthesis + LCL repair with suture anchor/transosseous tunnel was done. Coronoid and olecranon fixation was always performed. Patients were evaluated as follows: Q-DASH score, MEPI, pain according to VAS, range of motion, complications and radiographic findings and fracture union, and elbow instability.

RESULTS

The mean length of follow-up among the patients was 18 months. There were statistically significant differences between the DASH score/MEPS between radial head excision and replacement/reconstruction. Instability was significantly reduced in those with LCL reconstruction. Excising the comminuted radial head without replacement had the worst outcome. Best PROM was reported in patients with osteosynthesis.

CONCLUSION

Provided a standard protocol is applied, radial head osteosynthesis has preferable outcomes in terms of patient-related outcomes as compared to arthroplasty, although not statistically significant. Radial head excision though has acceptable outcomes but there is a restriction of movements especially flexion-extension. Acceptable rate of complications major or minor warrants need of secondary surgical procedures or a staged treatment.

A retrospective comparative cohort study of radial head arthroplasty versus resection in complex elbow dislocations

INTRODUCTION

The management of radial head fractures for the treatment of complex elbow dislocations remains controversial. Until the publication of recent therapeutic algorithms, different actions have been carried out, including resection or arthroplasty of the radial head. This study aims to compare the clinical and radiological results of these two techniques.

MATERIALS AND METHODS

A retrospective study was conducted between the years 2001 and 2016 in complex elbow dislocations associating comminuted fractures of the radial head (Mason type IV) for two cohorts: 20 patients who received a radial head prosthesis against 12 patients treated with resection. At the end of the follow-up, two functional valuation scales were applied: Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand score (DASH). Radiological study included the presence of post-traumatic osteoarthritis and heterotopic ossifications in both groups; and specific complications in the group of patients treated with an arthroplasty.

RESULTS

The average age of the sample was 52.2 years in the prosthesis group, and 58.5 for the resection group, with a mean follow-up of 83.8 and 163 months respectively. No statistically significant differences were found in the mean values of the MEPS scale between the two groups (p = 0.5). The mean DASH score was significantly higher in the resection group (29.8 versus 10.3 with p = 0.006). A significantly higher rate of reinterventions and heterotopic ossifications was documented in the group of patients treated with radial head excision. The rate of specific radiological complications in the prosthesis group was 45%.

CONCLUSIONS

Although radial head resection could be a valid treatment in this group of patients, radial head arthroplasty would remain as the main option for the treatment of these lesions.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Radial head arthroplasty: fixed-stem implants are not all equal-a systematic review and meta-analysis

Background

Numerous fixed-stem implants exist for radial head arthroplasty; therefore, we conducted a systematic review to compare the safety and efficacy of different types of fixed-stem implants.

Methods

We conducted a literature search, updated from a previous systematic review, to identify studies evaluating a fixed-stem radial head arthroplasty implant for any indication. We extracted data on revision rates, specific complications, and functional scores. We pooled results across studies using a random-effects method, using proportions for dichotomous data and mean values for functional scores. We analyzed outcomes by indication and specific implant.

Results

We included 31 studies. Studies included patients with radial head fractures only, terrible-triad injuries, or Essex-Lopresti injuries or included a heterogeneous population. We identified 15 different fixed-stem implants. The results of our analysis revealed that patients with terrible-triad injuries may be at an increased risk of revision and instability and patients with Essex-Lopresti injuries may be at an increased risk of arthritis, capitellar erosion, and osteolysis. After removing these outliers and pooling the results by specific device, we observed variability across devices in the rates of revision, arthritis, capitellar erosion, instability, and osteolysis, as well as in functional scores.

Conclusion

Differences were seen across different implants in revision rates, certain complications, and functional scores. This study highlighted that these devices should be evaluated within the context of the patient population under examination, as patients with Essex-Lopresti or terrible-triad injuries may demonstrate worse outcomes relative to those with a fracture only.

Why does radial head arthroplasty fail today? A systematic review of recent literature

Since the introduction of the radial head prosthesis (RHP) in 1941, many designs have been introduced. It is not clear whether prosthesis design parameters are related to early failure. The aim of this systematic review is to report on failure modes and to explore the association between implant design and early failure.A search was conducted to identify studies reporting on failed primary RHP. The results are clustered per type of RHP based on: material, fixation technique, modularity, and polarity. Chi-square tests are used to compare reasons for failure between the groups.Thirty-four articles are included involving 152 failed radial head arthroplasties (RHAs) in 152 patients. Eighteen different types of RHPs have been used.The most frequent reasons for revision surgery after RHA are (aseptic) loosening (30%), elbow stiffness (20%) and/or persisting pain (17%). Failure occurs after an average of 34 months (range, 0-348 months; median, 14 months).Press-fit prostheses fail at a higher ratio because of symptomatic loosening than intentionally loose-fit prostheses and prostheses that are fixed with an expandable stem (p < 0.01).Because of the many different types of RHP used to date and the limited numbers and evidence on early failure of RHA, the current data provide no evidence for a specific RHP design. Cite this article: EFORT Open Rev 2019;4:659-667. DOI: 10.1302/2058-5241.4.180099.

Ex situ reconstruction of comminuted radial head fractures: is it truly worth a try?

INTRODUCTION

Complex radial head fractures are difficult to treat. In cases where stable fixation cannot be achieved, radial head resection or primary arthroplasty are frequently performed. Ex situ reconstruction of comminuted fractures may also be an option. This technique has widely been neglected in the literature, and only two small case series report satisfactory results. The aim of the present case series was to determine the functional and radiological outcomes of ex situ reconstructed Mason III and Mason IV fractures. We expect that the on-table reconstruction of comminuted radial head fractures will lead to bony union with no avascular necrosis in the postoperative course, which will demonstrate that this operative procedure is a reasonable option.

PATIENTS AND METHODS

Two Mason type III and seven Mason type IV fractures (including four Monteggia-like lesions) were reconstructed ex situ. The mean age of the patients was 47 years (range 22-64). The clinical examination included RoM tests, elbow stability tests, and a neurological examination. The functional outcome was assessed with the MEPS and DASH score. The radiographic examination included a.p. and lateral views of the elbow to detect non-unions, inadequacy or loss of reduction, radial head necrosis, heterotopic ossifications and signs of posttraumatic arthritis.

RESULTS

The mean follow-up time was 39 months (range 11-64). The mean MEPS was 82 points (range 15-100), and the mean DASH score was 20 points (range 0-85). All ex situ-reconstructed radial heads survived, and no signs of avascular necrosis were observed. Bony union was achieved in all but one patient who presented with an asymptomatic non-union. Signs of posttraumatic arthritis were found in all patients. With regard to the radial head, neither secondary resection nor arthroplasty had to be performed. All patients returned to their pre-injury occupations.

CONCLUSION

Ex situ radial head reconstruction can be a reliable option in the surgical treatment of complex radial head fractures associated with severe elbow trauma. Even in the midterm follow-up, no signs of avascular necrosis were observed. Modern implants may even extend the indications for reconstruction in such cases.

LEVEL OF EVIDENCE

Level IV-retrospective cohort study.

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

Preserving the radial head in comminuted Mason type III fractures without fixation to the radial shaft: a mid-term clinical and radiographic follow-up study

BACKGROUND

The treatment of multifragment Mason type III fractures is challenging. Open reduction-internal fixation (ORIF), radial head arthroplasty, and in some cases, even radial head resection are the current options; however, each of these treatment methods is associated with characteristic benefits and complications. We present our experience with a radial head salvage procedure in comminuted radial head fractures irrespective of concomitant injuries, which are not accompanied by typical ORIF-related complications.

METHODS

The first group comprised 29 patients with multifragment Mason type III fractures treated surgically with biological radial head spacers (group S). The fragments were reduced and fixated in an extracorporeal manner, and the reconstructed radial head was placed in its anatomic position without fixation to the shaft. The second group comprised 12 patients treated with conventional ORIF using mini-fragment plates (group P).

RESULTS

Thirty patients were enrolled to undergo clinical and radiographic follow-up at an average of 76 months (range, 12-152 months). In group S, nonunion at the head-neck junction developed in 70% of the cases; however, the overall Mayo Elbow Performance Index averaged 94.8, which was superior to the average Mayo Elbow Performance Index of 83.1 in group P. Radiographic evaluation showed development of osteoarthritic changes in 75% of patients in group S and 62.5% in group P. None of the patients had wrist-joint pain.

CONCLUSIONS

Preserving the native radial head in comminuted Mason type III fractures without fixation to the radial shaft is a reliable option. Excellent functional results can be expected; however, the development of osteoarthritis cannot be impeded.

Midterm outcome of partial radial head replacement with a contoured iliac crest bone graft in complex elbow dislocation

PURPOSE

To report the midterm outcome of a novel reconstructive technique using a contoured iliac crest bone graft for partial radial head replacement in the treatment of complex elbow dislocation.

MATERIAL AND METHODS

Between January 2008 and December 2013, 10 patients (5 women, 5 men; mean age, 43.8 years; mean follow-up duration, 65.9 months) with complex elbow dislocation who underwent the partial radial head replacement with the contoured bone graft were included in the study. The irreparable radial head defects averaged 49% of the articular surface (range, 36-60%). The fracture involved the entire head in four patients and partial head in six patients.

RESULTS

At the final follow-up, the mean elbow extension was 8°, flexion 143°, supination 76.5°, and pronation 73°. The mean Mayo elbow performance index was 93.2 points and the Broberg-Morrey functional rating score was 94.1 points, with seven excellent cases, two good cases, and one fair case. Radiographic union was achieved in all but one, at an average time of 6.89 weeks (range, 6-10 weeks). The final radiographs demonstrated no evidence of degenerative change in eight patients, mild arthritis in one patient, and moderate arthritis in one patient.

CONCLUSION

This technique is a viable option in the treatment of the large radial head defect in complex elbow dislocation when more than 40% of the original head is still available for incorporation.

Surgical treatment of radial head isolated Mason III fractures

INTRODUCTION

In this retrospective study we have analyzed a consecutive series of patients affected by isolated radial head Mason III fractures and treated with bone resection or prosthesis.

PATIENTS AND METHODS

This study includes 24 patients affected by fractures mentioned above and treated between July 2009 and November 2015. 15 patients (average age 48 y.o.) have been treated with prosthesis. The remaining 9 (average age 573) have been treated with a capitellectomy instead. From a clinical point of view, we have evaluated the patients according to main performance indicators such as range of motion, pain, instability and Mayo Elbow Performance Score as parameters.

RESULTS

We have found similar results in both group, with an average MEPS value of 95 in the prosthesis group and 966 in the radial head resection group. The range of motion was similar too: between 1,3° and 1203° in the first group and between 4,4° and 120° in the second one. No significant complication has detected in any patient.

DISCUSSION

According to most recent literature, it is not precisely defined how to treat isolated Mason III fractures, contrary to what is defined in more complex pattern, in which prosthesis are now evaluated as the best indication. Due to radial head limited contribution to elbow stability, in absence of other bony or ligamentous lesions both capitellectomy and prosthesis can be good treatment in this kind of fracture.

CONCLUSION

According to our experience and to the most recent literature, we recommend prosthesis in patient younger than 50 y.o., high demanding or manual worker, while in other cases we think that radial head resection can be the treatment of choice.

Complex radial head and neck fractures treated with modern locking plate fixation

BACKGROUND

Internal fixation of complex radial head and neck (CRHN) fractures is difficult, and postoperative complications are common. This study evaluated elbow function and patient clinical status after internal fixation of CRHN fractures with modern locking plates.

METHODS

We included 40 patients with 41 fractures (1 bilateral lesion). In 25 patients (61%), a concomitant injury was found. Patients were an average age of 46 years (range, 22-70 years). The mean follow-up time was 36 months (range, 2-70 months). Postoperative assessments included evaluation of range of motion, functional scores, and radiologic findings. We assessed fracture healing, surgical complications, revision surgery, and the need for metal removal.

RESULTS

Of the 34 fractures available for follow-up, 33 (97%) healed well. The mean extension deficit was 6° (range, 0°-30°). The average elbow flexion was 134° (range, 90°-160°), pronation was 70° (range, 30°-90°), and supination was 64° (range, 20°-90°). The Mayo Elbow Performance Score showed a mean of 90 points (range, 65-100 points). We observed no "poor" results. The mean Disability of Arm, Shoulder and Hand score was 16.5 (range, 2.5-58.3; n = 29). All patients continued activity without daily analgesics. There were 12 (34%) complications. In 11 (32%) patients, the plate was removed.

CONCLUSIONS

CRHN fractures fixed with modern locking plates and treated as an osseoligamentous lesion exhibited promising midterm results. The new fixation devices represent an improvement in the treatment of this difficult and common fracture while reducing the need for joint replacement or radial head resection. Diagnosis and treatment of concomitant injuries should be emphasized.

Use of surgical glue for Mason type III radial head fractures: A case report

RATIONALE

A Mason type III radial head fracture, which is characterized by comminuted fragments of the radial head, is a severe injury. Open reduction and internal fixation (ORIF) is an alternative treatment method; however, the technique of using an on-table reduction in combination with surgical glue is rarely reported.

PATIENT CONCERNS

A 48-year-old man was admitted to our department with complaints of elbow pain after falling down. Elbow radiography and computed tomography (CT) demonstrated characteristics of fractures before the operation.

DIAGNOSIS

Radiographic images showed a Mason type III radial head fracture.

INTERVENTIONS

The patient underwent ORIF at our hospital. During the operation, the technique of on-table reconstruction combined with surgical glue was used.

OUTCOMES

The patient recovered well and was able to participate in his usual work.

LESSONS

Mason type III radial head fractures could be treated with ORIF, and a satisfactory result could be anticipated, thus avoiding a radial head replacement or resection. Anatomical reduction of a comminuted radial head could be obtained via an on-table reconstruction and application of surgical glue.

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.

Interventions for displaced radial head fractures: network meta-analysis of randomized trials

BACKGROUND

The purpose of this study was to conduct a systematic review of studies comparing treatments for displaced radial head fractures (RHFs) and perform a network meta-analysis of randomized controlled trials (RCTs).

METHODS

We searched electronic databases and reviewed the reference lists of included studies and prior systematic reviews. We included RCTs and cohort studies that (1) compared treatments for displaced RHFs in adults and (2) reported a functional outcome or postoperative complications. Data from RCTs were synthesized using a Bayesian network meta-analysis. We compared the proportion of patients categorized as "excellent" or "good" according to the Broberg and Morrey scale and the rate of postoperative complications using odds ratios (OR) with 95% credible intervals (CrI).

RESULTS

We included 20 studies (4 RCTs). The evidence from RCTs examined radial head arthroplasty (RHA), open reduction and internal fixation (ORIF) with metal implants (ORIF-M), and ORIF with biodegradable implants (ORIF-B). The network meta-analysis demonstrated that patients treated with an RHA had greater odds of achieving an "excellent" or "good" score compared with ORIF-M (OR, 22.5; 95% CrI, 2.73-299.58) and ORIF-B (OR, 11.83; 95% CrI, 0.58-324.57). For postoperative complications, RHA patients had a lower odds of experiencing a complication than ORIF-M (OR, 0.15; 95% CrI, 0.01-1.81) and ORIF-B (OR, 0.16; 95% CrI, 0.01-3.06) patients.

CONCLUSION

The network meta-analysis of RCTs indicated that RHA results in better function and reduced postoperative complications than ORIF-M and ORIF-B over 2 years in the treatment of displaced RHFs.

WITHDRAWN: Surgical treatment of radial head isolated Mason III fractures

The Publisher regrets that this article is an accidental duplication of an article that has already been published in Injury, 50(2) 2019 382–385, https://doi.org/https://doi.org/10.1016/j.injury.2018.11.044. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Radial head resection versus prosthetic arthroplasty in terrible triad injury: a retrospective comparative cohort study

Aims

The crucial role of the radial head in the stability of the elbow in terrible triad injury is acknowledged. This retrospective study aims to compare the results of resection of a severely comminuted radial head with or without prosthetic arthroplasty as part of the reconstruction for this injury.

Patients and Methods

The outcome of radial head resection was compared with prosthetic arthroplasty in 29 and 15 patients with terrible triad injuries, respectively. There were ten female patients (34.5%) in the resection group and six female patients (40%) in the prosthesis group. The mean age was 40.7 years (sd 13.6) in the resection group and 36 years (sd 9.4) in the prosthesis group. The mean follow-up of the patients was 24.4 months (sd 12) in the resection group and 45.8 months (sd 6.8) in the prosthesis group. Outcome measures included visual analogue scale (VAS) for pain, Mayo Elbow Performance Score (MEPS), Disabilities of Arm, Shoulder and Hand (DASH) Score, and range of movement. Postoperative radiological complications were also recorded.

Results

The mean ranges of extension, flexion, supination, and pronation were not significantly different between the two study groups (p = 0.75, p = 0.65, p = 0.82, and p = 0.68, respectively). The mean VAS score, DASH score, and MEPS of the two groups were also not statistically significantly different (p = 0.93, p = 0.19, and p = 0.32, respectively). At the final visit, the elbow was stable in all patients. No patient was found to have developed an Essex–Lopresti injury. Osteoarthritis grade I and II was observed in five and three patients of the resection group, respectively, and four and one patients of the arthroplasty group, respectively.

Conclusion

The outcome of patients undergoing treatment for terrible triad injuries is similar whether the patient’s radial head was excised or replaced. Cite this article: Bone Joint J 2018;100-B:1499–505.

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.

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.

Using an anatomically preshaped low-profile locking plate system leads to reliable results in comminuted radial head fractures

INTRODUCTION

For comminuted and displaced fractures of the radial head open reduction and internal fixation (ORIF) is recommended nowadays as the treatment of choice. Due to the development of locking plates the possibilities of ORIF in complex fracture types were extended. The purpose of this retrospective survey therefore was to review the preliminary subjective and objective results in patients treated by anatomically preshaped locked plating. A reliable fracture healing for these recently introduced plating devices was hypothesized.

MATERIALS AND METHODS

Subjective and objective criteria included patient's satisfaction, pain rating on a visual analogue scale (VAS) and active range of motion (ROM) compared to the contralateral armside. Functional scoring included the Morrey elbow performance score (MEPS), the QuickDASH and the elbow self-assessment score (ESAS). Furthermore, follow-up radiographs were reviewed.

RESULTS

Between 2011 and 2014 a total of 24 patients were managed with ORIF using anatomically preshaped low-profile locking plates. All patients had suffered from comminuted radial head fractures (type III-IV according to Mason classification). Twenty of 24 patients returned for follow-up examination after a mean of 30 months (range 18-53 months). Patients' satisfaction was rated as highly satisfied in 17 cases and satisfied in 3 cases. An unrestricted ROM for extension-flexion arc and pronation-supination arc was rated in 10 cases. Minor ROM deficiencies with a 5° limited extension compared to the contralateral side was evaluated in 6 cases. Only four patients were rated with and extension and supination deficiency of 10°, one of whom with an additional pronation deficiency of 10°. The calculated MEPS was Ø 98 ± 4 (range 85-100), and the QuickDASH was Ø 3 ± 6 (range 0-21). The ESAS was completed by 18 patients with a mean of Ø 96.54 ± 2.95 (range 94-100) indicating a non-restricted elbow function.

CONCLUSIONS

The treatment of comminuted radial head fractures using anatomically preshaped locking radial head plates represents a reliable and safe surgical approach, leading to good to excellent functional results. Being aware of the importance of the radial head for elbow stability, open reduction and internal fixation should be preferred prior to radial head resection or replacement in complex radial head fractures. Further trials with a higher number of patients are needed to confirm the advantages of preshaped radial head plates.