High Risk of Further Surgery After Radial Head Replacement for Unstable Fractures: Longer-term Outcomes at a Minimum Follow-up of 8 Years

Demographics, Indications, and Revision Rates for Radial Head Arthroplasty: Analysis of Data from the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

Population-level data from national arthroplasty registries enable the use and outcomes of arthroplasty procedures to be monitored over time. This study aimed to describe the demographics, indications, and outcomes (up to 15 years) for radial head arthroplasty (RHA) procedures in Australia, as well as the factors associated with an increased likelihood of revision.

METHODS

Individual-level deidentified data on demographics and surgery characteristics, including revision surgery, were obtained from the Australian Orthopaedic Association National Joint Replacement Registry for all primary isolated RHA procedures that had been performed from 2007 to 2021. The probability of prosthesis survival was determined using Kaplan-Meier estimates. Cox proportional hazards models were used to calculate hazard ratios (HRs) for revision.

RESULTS

A total of 3,457 primary RHAs were performed during the study period (mean follow-up, 5.6 years; range, 0 to 15 years). The mean age at the time of RHA was 53 years, with female predominance (n = 2,009, 58%). The most common indication for RHA was fracture or dislocation (n = 3,166, 92%), followed by osteoarthritis (n = 232, 7%). The radial head prostheses that were most commonly used were monopolar (n = 3,378, 98%) with a modular design (n = 3,442, 99.6%) and cementless fixation (n = 3,387, 98%). Both metallic and nonmetallic prostheses were used (52% and 48%, respectively). Of the total cohort, 160 revisions (5%) were performed during the 15-year period; most revisions occurred in the first 5 years. The most common revision indication was prosthesis loosening (n = 62, 39%), and 54% of the revisions (n = 87) involved a change of the radial component. In multivariable analysis, primary procedures for osteoarthritis (HR, 1.65; 95% confidence interval [CI], 1.01 to 2.70) or "other" indications (e.g., inflammatory arthritis, osteonecrosis, or tumor) were revised more frequently (HR, 3.68; 95% CI, 1.14 to 11.91) than procedures for fracture or dislocation. Procedures with nonmetallic prostheses had higher rates of revision (HR, 1.61; 95% CI, 1.17 to 2.22) than those with metallic prostheses.

CONCLUSIONS

Trauma remained the most prevalent indication for RHA in Australia from 2007 to 2021. Encouragingly, revision rates were low, most notably for RHA that had been performed for fracture or dislocation. The likelihood of revision was highest for RHA procedures performed for osteoarthritis and for an indication other than osteoarthritis or trauma. Nonmetallic prostheses had a higher rate of revision than metallic prostheses.

LEVEL OF EVIDENCE

Therapeutic Level III. 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.

Silicone radial head prostheses revisited: do they have a role in today's practice? A systematic review of literature on clinical outcomes

BACKGROUND

Silicone radial head prostheses (SRHP) are considered obsolete due to reports of frequent failure and destructive silicone-induced synovitis. Considering the good outcomes of modern non-radial silicone joint implants, the extent of scientific evidence for this negative view is unclear. The aim of this research was to systematically analyze the clinical evidence on complications and outcomes of SRHP and how SRHP compare to both non-SRHP and silicone prostheses of other joints.

METHODS

A systematic literature review was conducted through the Cochrane, PubMed, and Embase databases.

RESULTS

Eight cohort studies were included, consisting of 142 patients and follow-up periods ranging from 23 months to 8 years. Average patient satisfaction was 86%, range of 71%-100%, and 58 complications were seen, but no cases of synovitis. These outcomes were in line with non-SRHP. Four case series with 11 cases of synovitis were found, all due to implant fractures years to decades after implantation. Six systematic reviews of currently used non-radial silicone joint implants showed excellent outcomes with low complication rates.

CONCLUSIONS

Since SRHP have satisfactory clinical results and an acceptable complication rate when selecting a patient group in suitable condition for surgical indications, it is considered that SRHP can still be chosen as a potential surgical treatment method in current clinical practice.

[Terrible triad injuries]

The complex injury pattern of a posterior elbow dislocation with concomitant radial head and coronoid fractures is usually referred to as a terrible triad injury. Due to the concomitant compromise of several osteoligamentous structures of the elbow joint relevant for stability, these injuries pose a particularly major challenge to the treating trauma surgeons. For this reason, a careful preoperative analysis of all relevant injury components is mandatory in order to make an adequate treatment decision. In most cases, surgical treatment addressing all elements relevant for stability is necessary to achieve a stable and congruent elbow joint. Only this enables early functional follow-up treatment and minimizes the complication rate. Delayed or even insufficient treatment with persistent (sub)dislocation must be avoided at all costs, otherwise there is a high risk of serious posttraumatic functional disorders of the elbow with rapid progression of osteoarthritis.

Radial Head Arthroplasty for Fracture: Implant Survivorship and Outcomes at Mean Follow-up of 8 Years

PURPOSE

The purpose of this study was to evaluate implant survivorship and clinical outcomes following radial head arthroplasty for fracture at long-term follow-ups.

METHODS

A retrospective analysis was conducted on adult patients who underwent primary uncemented radial head arthroplasty for radial head or neck fractures between 2012 and 2015. Medical records were reviewed to collect information regarding demographics, injury characteristics, reoperations, and revisions requiring implant removal. A bivariate analysis was conducted to identify potential risk factors for reoperation. A Kaplan-Meier curve was created to determine implant survival rates. Eligible patients were contacted to confirm any reoperations and obtain Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups.

RESULTS

A total of 89 patients were eligible for analysis and assessed at a mean of 97 months after surgery (range, 81-128). Reoperation rate was 16% (14 of 89 patients), including 5% of patients requiring implant removal or revision. However, 93% of reoperations occurred within the first 12 months of the index surgery. Fracture dislocations of the elbow had a higher rate of reoperation. A Kaplan-Meier curve demonstrated an implant survival rate of 96% at 10-year follow-up. Of the patients who responded, the mean Quick Disability of the Arm, Shoulder, and Hand score was 8.7 ± 10.3, with none requiring additional reoperations or revisions. There were otherwise similar outcome scores among patients requiring reoperation versus those who did not.

CONCLUSIONS

Although radial head arthroplasty for fractures has a high potential for reoperation within the first year, survival rates with uncemented implants remain high at 10 years, and patients report excellent Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups, despite any need for reoperation. Fractures with associated elbow dislocation may be at a higher risk for reoperation, and it is important to provide this prognostic information to patients who are likely to require arthroplasty for more extensive injuries.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The use of intramedullary devices for adult radial head and neck fractures. A systematic review

The management of isolated radial neck and head fractures is controversial. Plate fixation and tripod fixation are two commonly employed techniques but risk damage to soft tissues and implant-related complications. Intramedullary fixation is commonly used in pediatric cases and reduces the potential drawbacks of open fixation. This systematic review aimed to analyze outcomes of intramedullary fixation in adults in terms of function, union, and complication rates. A systematic review of the literature was conducted following the PRISMA guidelines using Medline and EMBASE's online databases. The review was registered on the PROSPERO database. Studies were appraised using the Methodological Index for non-randomized studies (MINORS) tool. Seven studies were deemed eligible for inclusion (n=55). Mean ages of patients ranged from 31.3 to 44.2 years, and mean follow-up ranged from 9 to 86 months. The Mayo Elbow Performance score (MEPs) was reported in five case series (mean scores 81.8 -97.9) and the prevalence of excellent results ranged from 71% and 83%. Although 100% of fractures united, the pooled complication rate was 24% (range 0-50%). The most common complications were elbow stiffness (7%), superficial radial nerve neuropraxia (7%), malunion (5%), and AVN (1.8%). No study reported any patients requiring revision surgery. Intramedullary fixation for radial head and neck fractures appears to provide a reliable alternative treatment option in terms of union, range of motion, and functional outcomes. Further robust trials direct comparing against open fixation techniques are required.

Coronoid tip fractures in terrible triad injuries can be safely treated without fixation

INTRODUCTION

The optimal treatment of terrible triad injuries of the elbow (TTI) remains topic of ongoing discussion. The aim of this study was to determine whether different treatment strategies for coronoid tip fractures in terrible triad injuries influences the clinical and radiological results in a mid-term follow-up.

METHODS

A total of 62 patients with surgical treatment of a TTI including a coronoid tip fracture (37 women, 25 men; mean age, 51 years) were available for follow-up assessment after an average of 4.2 years (range 24-110 months). Thirteen patients had O'Driscoll 1.1 and 49 O'Driscoll 1.2 coronoid fractures, of which 26 were treated with and 36 without fixation. Range of motion, the Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder and Hand (DASH) score as well as grip strength were evaluated. Radiographs were analyzed for all participants.

RESULTS

No significant benefit in outcome variables could be detected between patients, whose coronoid had been fixed, compared to patients without fixation of the coronoid. In the coronoid fixation group, patients had mean outcome scores of 81.5 ± SD 19.1 (range 35-100) for MEPS, 31.0 ± SD 12.5 (range 11-48) for OES and 27.7 ± SD 23 (range 0-61) for DASH score, while in the no-fixation group, mean MEPS was 90.8 ± SD 16.5 (range 40-100), mean OES was 39.0 ± SD 10.4 (range 16-48) and mean DASH score was 14.5 ± SD 19.9 (range 0-48). Mean range of motion was 116° ± SD 21° (range 85-140°) versus 124° ± SD 24° (range 80-150°) in extension-flexion and 158° ± SD 23° (range 70-180°) versus 165° ± SD 12° (range 85-180°) in pronation-supination. Overall complication rate was 43.5% and revision rate was 24.2%, with no significant differences between both groups. Suboptimal results were more frequently seen in patients who had degenerative or heterotopic changes on their latest radiograph.

CONCLUSIONS

Sufficient elbow stability and good outcomes can be achieved in most patients with TTI and coronoid tip fractures. Although some bias in treatment allocation and group heterogeneity cannot be completely omitted, our analysis detected no significant benefit in outcome when the coronoid tip fracture has been fixed compared to patients with non-fixed coronoid tip. Therefore, we would suggest a no-fixation approach for coronoid tip fractures as primary treatment in TTI of the elbow.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

After failed radial head arthroplasty, what are the options? Risk factors and results of revisions in a multicenter study

Introduction

Few multicenter studies have analyzed the outcome of revision surgery of radial head arthroplasties (RHA) in the medium term follow up. The objective is twofold: to determine the factors associated with revision of RHAs and to analyze the results of revision with 2 surgical techniques: isolated removal of the RHA or revision with a new RHA (R-RHA).

Hypothesis

There are associated factors of RHA revision and RHA revision results in satisfactory clinical and functional outcomes.

Methods

Twenty-eight patients were included in this multicenter retrospective study, with all surgical indications for initial RHA being traumatic/post-traumatic. The mean age was 47 ± 13 years with a mean follow-up of 70 ± 48 months. This series included two groups: the isolated RHA removal group (n = 17) and the revision RHA with new radial head prosthesis (R-RHA) group (n = 11). Evaluation was clinical and radiological with univariate and multivariate analysis.

Results

Two factors associated with RHA revision were identified: a pre-existing capitellar lesion (p = 0.047) and a RHA placed for a secondary indication (<0.001). Revision for all 28 patients resulted in improved pain (pre-op Visual Analog Scale 4.7 ± 3 vs. post-op 1.57 ± 2.2, p < 0.001), mobilities (pre-op flexion 118 ± 20 vs. post-op 130 ± 13, p = 0.03; pre-op extension -30 ± 21 vs post-op -20 ± 15, p = 0.025; pre-op pronation 59 ± 12 vs post-op 72 ± 17, p = 0.04; pre-op supination 48 ± 2 vs post-op 65 ± 22, p = 0.027) and functional scores. Mobility and pain control were, for stable elbows, satisfactory in the isolated removal group. When the initial or revision indication was instability, the DASH (Disabilities of the Arm, Shoulder and Hand = 10 ± 5) and MEPS (Mayo Elbow Performance score = 85 ± 16) scores were satisfactory in the R-RHA group.

Discussion

In the case of a radial head fracture, RHA is a satisfactory first-line solution without pre-existing capitellar injury, its results being much weaker in the case of ORIF failure and fracture sequelae. In case of RHA revision, isolated removal or R-RHA adapted according to the pre-operative radio-clinical exam.

Level of evidence

IV.

Complications, Reoperations, and Long-Term Outcomes after Open Reduction Internal Fixation of Mason Classification Type II and Type III Radial Head Fractures

Introduction  The objectives of this study were to assess long-term outcomes, complications, and reoperations after open reduction internal fixation (ORIF) of radial head fractures. Materials and Methods  35 adult patients, who underwent ORIF of an isolated, displaced radial head fracture without elbow instability (Mason classification type II or III) at two tertiary care referral centers from 2000 to 2017, were identified. Patient satisfaction, pain, and QuickDASH scores were assessed by telephone follow-up at median 12.9 years. Results  The mean age of the 35 patients in our study was 39 years, and 54% were women. The median length of clinical follow-up was 175 days. Postoperative complications occurred in 54% of patients, and reoperations in 23% of patients. Multivariable logistic regression identified fixation with plate and screws versus screws alone as a risk factor for complications and reoperations. The long-term telephone follow-up response rate was 54%. At 13-year median follow-up, the average patient satisfaction was 9.6/10, the average patient-reported pain was 0.7/10, and the average QuickDASH score was 10.5. Conclusion  The long-term outcomes of ORIF of Mason classification type II and III radial head fractures are favorable; however, rates of complication and reoperation are notable and may be higher with plate-and-screw fixation.

Pathologic Periprosthetic Fracture After Radial Head Arthroplasty: A Report of 2 Cases

CASE

We present 2 cases of pathologic periprosthetic radius fractures in the setting of osteolysis after radial head arthroplasty (RHA) with a porous-coated, press-fit implant. Both patients were managed with implant removal without subsequent instability. Although radiographic lucencies are common after RHA, progressive bone resorption can result in subsequent periprosthetic fractures.

CONCLUSION

Although osteolysis after RHA is not always clinically significant, these cases demonstrate that this radiographic finding may indicate adverse clinical consequences. Surgeons who perform implant excision should be ready to address further instability as needed.

LEVEL OF EVIDENCE

Level V, case reports.

Clinical long-term results of radial head arthroplasty in comminuted radial head fractures

Modern radial head prostheses have recently become more common in the treatment of comminuted radial head fractures. The goal of this study was to evaluate how well the EVOLVE^® modular metallic radial head implant prosthetic restores the functional range of motion and stability of the elbow. 30 patients with comminuted radial head fractures received an arthroplasty with an EVOLVE^® prosthesis in our institution. 20 of those patients were available for long-term follow-up (mean > 10 years). The outcomes were assessed on the basis of pain, motion, and strength. The overall outcome was scored with functional rating scores. According to the Broberg-Morrey elbow evaluation score, after a mean follow-up period of 10.2 years, ten (50.0%) patients were rated as very good, four (20.0%) as good, six (30.0%) as satisfactory, and none as poor. In the long-term results the Broberg-Morrey score increased from 79 (in short-term results) to 89 points. The Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure questionnaire showed an average of 16.2 points. Initially, patients had an extension deficit of 20°, which was reduced to 5° at the latest follow-up. In our long-term results, an improvement in the function of the elbow was observed after arthroplasty using a metallic modular radial head implant. Comminuted radial head fractures with elbow instability can be treated effectively with the EVOLVE^® radial head prosthesis, which restores stability in acute treatment. Our long-term results after 10.2 years demonstrate good functional outcome and low major complication rate. IV.

Patient and Surgeon Factors Associated With Prosthetic Replacement Rather Than With Open Reduction and Internal Fixation of a Radial Head Fracture

Background: The decision between radial head arthroplasty and open reduction internal fixation in the context of a terrible triad elbow fracture-dislocation is debated. This study investigated both surgeon and patient factors associated with surgeons' recommendations to use arthroplasty. Methods: One hundred fifty-two surgeon members of the Science of Variation Group participated. Surgeons were asked to complete an online survey that included surgeon demographics and 16 patient scenarios. The patient scenarios were randomized using 2 patient variables and 2 anatomical variables. Multilevel logistic mixed regression analysis was performed to identify surgeon and patient variables associated with recommendations for radial head arthroplasty. Results: We found that radial head replacement was recommended in 38% of the scenarios. Scenarios with older patients, with fractures of the whole head, and those involving 3 fracture fragments were independently associated with radial head replacement. Conclusion: We found that most surgeons recommended radial head fracture fixation rather than arthroplasty. Surgeons were more likely to recommend fixation for younger patients with partial articular fractures or with fractures with 3 or fewer fracture fragments. It seems that surgeons are uneasy about using a prosthesis in a young active patient.

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).

Silicone radial head prostheses: the clinical course and treatment of failure-a case series

INTRODUCTION

Silicone radial head prostheses (SRHP) have a reputation of acceptable initial function but failure in the medium to long term as a result of the disintegration of the silicone material. Damaged SRHP can result in a silicone-induced synovitis and destruction of the joint. Early removal of damaged SRHP may prevent joint destruction. Literature is scarce; there are no studies describing early symptoms associated with clinical failure of SRHP and very few studies on appropriate treatment of destructed SRHP. The aim of this study was to describe the clinical course of failing SRHP and to provide practical guidance for treatment.

METHODS

Fifteen consecutive cases of failed SRHP, operated between 2005 and 2020, were retrospectively reviewed, using patient logs, radiographic results, and a questionnaire. Relevant data concerning pre- and postoperative complaints, function, and surgical details were gathered. Using the questionnaire, retrospective and current patient reported outcomes including Single Assessment Numeric Evaluation (SANE) scores, pain, instability, and range of motion were analyzed.

RESULTS

The average time between implantation of the SRHP until outpatient presentation was 16 years. The average recalled SANE score before start of complaints was 8.6 out of 10 points. In 4 patients, the onset of complaints was preceded by a trauma. Five patients had symptoms for more than a year, and 9 patients for several months. Progressive pain in the elbow and/or wrist and mechanical symptoms were early and prominent symptoms of failure. Clinical signs of synovitis were frequently present. The majority of patients had a slow but progressive onset of complaints over several months before presentation. Twelve of 15 cases of failed SRHP were surgically treated. Fragmentation of the implant, osteoarthritis, and synovitis were found in all surgically treated cases. Both surgical removal and synovectomy alone, and revision to a new radial head prosthesis resulted in good medium-term outcomes with a mean SANE score of 7.3 points at 8.4 years of follow-up. Postoperative extension lags and mild instability were frequently mentioned as a reason for reimplantation of a metallic radial head implant and removal of the radial head alone, respectively.

CONCLUSION

Both patients and physicians should be aware of early symptoms of a failing SRHP. Adequate recognition, radiographic evaluation, and early intervention may favor outcomes of failing SRHP. Surgical removal is easy to perform. In selected cases, revision of the radial head prosthesis may be considered. Both of these treatment strategies resulted in satisfying outcomes.

30-Day outcomes analysis of surgical management of radial head fractures comparing radial head arthroplasty to open reduction internal fixation

INTRODUCTION

Radial head arthroplasty and open reduction internal fixation are two commonly utilized treatment options for radial head fractures. The purpose of this study is to assess the incidence of and risk factors for short-term complications following radial head arthroplasty and open reduction internal fixation of radial head fractures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients that underwent radial head arthroplasty or open reduction internal fixation for radial head fractures between January 1st, 2015 and December 31st, 2017. The incidence of various 30-day complications, including unplanned readmission, reoperation, non-home discharge, mortality, surgical/medical complications, and extended length-of-stay were compared between the two propensity matched groups. Multivariate logistic regression was used to identify independent risk factors for various short-term complications.

RESULTS

After propensity matching, a total of 435 patients were included in our analysis. 250 patients underwent radial head arthroplasty, and 185 patients underwent open reduction internal fixation. Arthroplasty treated patients had a significantly longer mean total operative time (p = .031) and length-of-stay (p = .003). No significant 30-day complications differences were found for unplanned readmission, reoperation, non-home discharge, mortality, surgical complications or medical complications. Independent risk factors for any complications of both procedures included a history of chronic obstructive pulmonary disease and American Society of Anesthesiologists class III. Significant risk factors for length-of-stay greater than two days included a history of bleeding disorder and American Society of Anesthesiologists class III.

CONCLUSION

Our study revealed there were no significant differences in 30-day perioperative surgical or medical complications from either surgical treatment of radial head fractures; however, radial head arthroplasty treated patients were met with a significantly longer length-of-stay and longer duration of operating time. We also identified risk factors that were independently associated with higher rates of complications regardless of treatment type.

Long-term outcomes of radial head arthroplasty for radial head fractures-a systematic review at minimum 8-year follow-up

BACKGROUND

The purpose of this study was to systematically review the literature to evaluate the functional outcomes, radiologic outcomes, and revision rates following radial head arthroplasty (RHA) at a minimum of 8 years follow-up.

METHODS

Two independent reviewers performed a literature search using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using PubMed, Embase, and Web of Science databases. Only studies reporting on outcomes of RHA with a minimum of mean 8 years' follow-up were considered for inclusion.

RESULTS

Our search found 10 studies including 432 elbows (51% males), with average age of 50 years (15-93) and mean follow-up of 117 months (98-145) met our inclusion criteria. At final follow-up, the mean Mayo Elbow Performance Score and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score were 83 (45-100) and 17 (0-63) respectively, and 86% of patients reported having no or minimal pain. The overall dislocation, subluxation, ulnar neuritis, and infection rates were 2%, 4%, 3%, and 3%, respectively. The rates of radiologic loosening, radiolucency, degenerative change, and heterotopic ossification were 9%, 46%, 27%, and 38%, respectively. The overall surgical revision rates were 20%, with 3%, 15%, and 5% requiring RHA implant revision, removal of metal or implants, and arthrolysis, respectively.

CONCLUSION

Our systematic review established that RHA results in satisfactory clinical outcomes and modest complication and revision rates at long-term follow-up, despite high levels of radiologic degenerative changes over the same period.

Long-Term Outcomes of Radial Head Arthroplasty in Complex Elbow Fracture Dislocation

The purpose of the current study was to investigate the long-term outcomes of radial head arthroplasty in complex elbow injuries through radiographic analysis and functional correlation. We evaluated 24 radial head arthroplasties in 24 consecutive patients with complex elbow fracture dislocation. All patients were treated with a single type of modular monopolar prosthesis containing smooth stem in press-fit implantation. Clinical survey using the Mayo Elbow Performance Score (MEPS), self-reported scales of shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and the visual analog scale (VAS) at more than 10-year follow-up were reported and compared to 2-year outcomes. Periprosthetic osteolysis was measured in the 10 zones of prosthesis-cortical interface with a modified radiolucency score, which was calibrated by each prosthesis size. Pearson correlation analysis was performed to detect the association between periprosthetic radiolucency and clinical assessment. At the final follow-up, MEPS, QuickDASH score and VAS score averaged 82.5 ± 15, 14.1 ± 14.3 and 1.6 ± 1.2 respectively. A decline in functional status was noted, with decreased mean MEPS and increased mean QuickDASH and VAS scores as compared to the 2-year results while the difference was insignificant. Periprosthetic osteolysis was more prevalent around stem tip of zone 3 and zone 8. The final and 2-year radiolucency scores averaged 7.4 ± 4.2 and 2.6 ± 2.3 respectively with significant difference. Pearson correlation analysis indicated that the difference between radiolucency scores and clinical outcomes in MEPS/QuickDASH/VAS was -0.836, 0.517 and 0.464. Progression of periprosthetic osteolysis after postoperative 10 years is more prevalent around the stem tip with moderate to high correlation to clinical outcomes. Sustained follow-up is warranted to justify subsequent surgery for revision or implant removal.

Long-term outcome and survival rate of monopolar radial head replacement

BACKGROUND

The purposes of this study were (1) to report functional outcomes; (2) to assess complications, revisions, and survival rate; and (3) to assess differences in functional outcomes between removed and retained radial head arthroplasties (RHAs), early and delayed treatment, and type of RHA used at long-term follow-up after monopolar RHA for unreconstructible radial head fractures or their sequelae.

METHODS

Seventy-eight patients (mean age, 59.2 years) who were at least 6 years postoperatively after monopolar RHA for unreconstructible RHFs or their sequelae were included. The Mayo Elbow Performance Score (MEPS); Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) score; visual analog scale; postoperative satisfaction (1-6, 6 = highly unsatisfied); range of motion; complications; and revisions were assessed. Radiographic findings were reported. Kaplan-Meier survival analysis was performed. Subgroups (RHA type, early vs. delayed surgery, RHA removed vs. retained) were compared.

RESULTS

At a median clinical follow-up of 9.5 years (range: 6.0-28.4 years), median MEPS was 80.0 (interquartile range [IQR]: 60.0-97.5), median QuickDASH was 22.0 (IQR: 4.6-42.6), median visual analog scale was 1 (IQR: 0-4), median postoperative satisfaction was 2 (IQR: 1-3), and median arc of extension/flexion was 110° (IQR: 80°-130°). Radiographic follow-up was available for 48 patients at a median of 7.0 years (range: 2.0-15.0 years). Heterotopic ossifications were seen in 14 (29.2%), moderate-to-severe capitellar osteopenia/abrasion in 3 (6.1%), moderate-to-severe ulnohumeral degeneration in 3 (6.1%), and periprosthetic radiolucencies in 17 (35.4%) patients. Twenty-nine patients (37.2%) had complications and 20 patients (25.6%) underwent RHA exchange or removal. Kaplan-Meier analysis with failure defined as RHA exchange or removal demonstrated survival of 75.1% (95% confidence interval: 63.7-83.3) at 18 years. The highest annual failure rate was observed in the first year in which the RHAs of 7 patients (9%) were exchanged or removed. No significant differences were detected between type of RHA in MEPS (Mathys: 82.5 [75.0-100] vs. Evolve: 80.0 [60.0-95.0]; P = .341) and QuickDASH (Mathys: 12.5 [0-34.4] vs. Evolve: 26.7 [6.9-46.2]; P = .112). Early surgery (≤3 weeks) yielded significantly superior MEPS (80.0 [70.0-100.0] vs. 52.5 [30.0-83.8]; P = .014) and QuickDASH (18.6 [1.5-32.6] vs. 46.2 [31.5-75.6]; P = .002) compared with delayed surgery (>3 weeks). Patients with retained RHAs had significantly better MEPS (80.0 [67.5-100] vs. 70.0 [32.5-82.5]; P = .016) and QuickDASH (18.1 [1.7-31.9] vs. 49.1 [22.1-73.8]; P = .007) compared with patients with removed RHAs.

CONCLUSIONS

Long-term outcomes for RHA are satisfactory; however, there is a high complication and revision rate, resulting in implant survival of 75.1% at 18 years with the highest annual failure rate observed in the first postoperative year.

Risk Factors for Revision Surgery Following Radial Head Arthroplasty without Cement for Unreconstructible Radial Head Fractures: Minimum 3-Year Follow-up

BACKGROUND

Revision rates following radial head arthroplasty (RHA) for unreconstructible radial head fractures (RHFs) differ vastly in the literature, and little is known about the risk factors that are associated with revision surgery. The purposes of this study were to assess the revision rate following RHA and to determine the associated risk factors.

METHODS

A total of 122 patients (mean age, 50.7 years; range, 18 to 79 years) with 123 RHAs who underwent RHA for unreconstructible RHFs between 1994 and 2014 and were ≥3 years out from surgery were included. Demographic variables, injury and procedure-related characteristics, radiographic findings, complications, and revision procedures were assessed. Cox regression analysis was performed to identify the risk factors that were associated with revision surgery following RHA.

RESULTS

The median follow-up for the study cohort was 7.3 years (interquartile range [IQR], 5.1 to 10.1 years). All of the patients had unreconstructible RHFs: Mason-Johnston type-IV injuries were the most prevalent (80 [65%]). One or more associated osseous or ligamentous injuries were seen in 89 elbows (72.4%). The median time to surgery was 7 days (IQR, 3 to 11 days). Implanted prostheses were categorized as rigidly fixed (65 [52.8%]) or loosely fixed (58 [47.2%]). A total of 28 elbows (22.8%) underwent revision surgery at a median of 1.1 years (IQR, 0.3 to 3.8 years), with the majority of elbows (17 [60.7%]) undergoing revision surgery within the first 2 years. The most common reason for revision surgery was painful implant loosening (14 [29.2% of 48 complications]). Univariate Cox regression suggested that Workers' Compensation claims (hazard ratio [HR], 5.48; p < 0.001) and the use of an external fixator (HR, 4.67; p = 0.007) were significantly associated with revision surgery.

CONCLUSIONS

Revision rates following RHA for unreconstructible RHFs are high; the most common cause for revision surgery is painful implant loosening. Revision surgeries are predominantly performed within the first 2 years after implantation, and surgeons should be aware that Workers' Compensation claims and the use of an external fixator in management of the elbow injury are associated with revision surgery.

LEVEL OF EVIDENCE

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

Surgical treatment of the radial head is crucial for the outcome in terrible triad injuries of the elbow

AIMS

To evaluate the outcomes of terrible triad injuries (TTIs) in mid-term follow-up and determine whether surgical treatment of the radial head influences clinical and radiological outcomes.

METHODS

Follow-up assessment of 88 patients with TTI (48 women, 40 men; mean age 57 years (18 to 82)) was performed after a mean of 4.5 years (2.0 to 9.4). The Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder and Hand (DASH) score were evaluated. Radiographs of all patients were analyzed. Fracture types included 13 Mason type I, 16 type II, and 59 type III. Surgical treatment consisted of open reduction and internal fixation (ORIF) in all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) was performed if reconstruction was not possible.

RESULTS

At follow-up the mean MEPS was 87.1 (20 to 100); mean OES, 36.9 (6 to 48); and mean DASH score, 18.6 (0 to 90). Mean movement was 118° (30° to 150°) for extension to flexion and 162° (90° to 180°) for pronation to supination. The overall reoperation rate was 24%, with nine ORIF, ten RHA, and two patients without treatment to the radial head needing surgical revision. When treated with RHA, Mason type III fractures exhibited significantly inferior outcomes. Suboptimal results were also identified in patients with degenerative or heterotopic changes on their latest radiograph. In contrast, more favourable outcomes were detected in patients with successful radial head reconstruction after Mason type III fractures.

CONCLUSION

Using a standardized protocol, sufficient elbow stability and good outcomes can be achieved in most TTIs. Although some bias in treatment allocation, with more severe injuries assigned to RHA, cannot be completely omitted, treatment of radial head fractures may have an independent effect on outcome, as patients subjected to RHA showed significantly inferior results compared to those subjected to reconstruction, in terms of elbow function, incidence of arthrosis, and postoperative complications. As RHA showed no apparent advantage in Mason type III injuries between the two treatment groups, we recommend reconstruction, providing stable fixation can be achieved. Cite this article: Bone Joint J 2020;102-B(12):1620-1628.