Biomechanical comparison of three fixation strategies for radial head fractures: a biomechanical study

Second-generation headless compression screws (HCSs) are commonly used for the fixation of small bones and articular fractures. However, there is a lack of biomechanical data regarding the application of such screws to radial head fractures. This study evaluated the mechanical properties of the fixation of radial head fractures using a single oblique HCS compared with those obtained using a standard locking radial head plate (LRHP) construct and a double cortical screw (DCS) construct. Radial synbone models were used for biomechanical tests of HCS, LRHP, and DCS constructs. All specimens were first cyclically loaded and then loaded to failure. The stiffness for the LRHP group was significantly higher than that for the other two groups, and that for the HCS group was significantly higher than that for the DCS group. The LRHP group had the greatest strength, followed by the HCS group and then the DCS group. The HCS construct demonstrated greater fixation strength than that of the commonly used cortical screws, although the plate group was the most stable. The present study revealed the feasibility of using a single oblique HCS, which has the advantages of being buried, requiring limited wound exposure, and having relatively easy operation, for treating simple radial head fractures.

The Relationship between the Bevel of the Radial Head Epiphysis and the Posterior Synovial Fringe During Rotation of the Elbow: An Ultrasonography Study with Possible Implications Regarding the Pathophysiology of Nursemaid's Elbow

BACKGROUND

Nursemaid's elbow is the most common upper extremity injury in children under 5 years of age. However, the exact pathomechanism underlying the nursemaid's elbow remains elusive, and approximate one-third of patients present with a nonclassical history. Using a high-frequency ultrasound probe, we attempted to determine the relationship between the anterior edge of the posterior synovial fringe and the peripheral rim of the radial head epiphysis during rotation. It is possible that the primary reason for the nursemaid's elbow is due to the pronator position.

METHODS

Twenty-one patients had a history of nursemaid's elbow and had a successful reduction before enrollment in this study. A high-frequency linear array 6 to 24 MHz hockey stick transducer was used to detect small morphologic changes in the peripheral rim of the radial head epiphysis and the posterior synovial fringe during rotation of the capitellum-radial joint.

RESULTS

In complete pronation, the anterior edge of the posterior synovial fringe contacts the beveled articular surface of the radial head peripheral rim in all 21 patients. In neutral and complete supination, the anterior edge of the posterior synovial fringe contacts the convexly nonarticular surface of the radial head peripheral rim and extends deep into the foveal radius. The posterior synovial fringe and the capsule-aponeurotic membrane were tightened in passive pronation in all 21 cases. The posterior synovial fringe and the capsule-aponeurosis membrane were all loose in the neutral and supination positions.

CONCLUSION

The anterior edge of the posterior synovial fringe touches the beveled peripheral rim of the radial head epiphysis during complete pronation, and the tension of the lateral collateral ligament complex during pronation may further cause unstable conditions of the anterior edge of the posterior synovial fringe. We hypothesized that the beveled peripheral rim of the radial epiphysis and its relationship with the anterior edge of the posterior synovial fringe could be the reason why nursemaid's elbow only occurs while the elbow is in the pronator position.

Radial head replacement with the 3D-printed patient-specific titanium prosthesis: Preliminary results of a multi-centric prospective study

PURPOSE

To report preliminary clinical results and safety of 3D-printed patient-specific titanium radial head (RH) prosthesis in treatment of the irreparable RH fractures.

MATERIAL AND METHODS

This multi-centric prospective study included 10 patients (6 men and four women, mean age 41 years (range, 25-64 years)). Three cases were classified as Mason type III and 7 cases as type IV. Patients were assessed preoperatively, intraoperatively, and at 1, 6, 12, 24, 36, and 48 weeks postoperatively. Range of motion (ROM), visual analog scale (VAS) score, Disabilities of the Arm, Shoulder and Hand (DASH) score, Mayo Elbow Performance Score (MEPS), radiology imaging, and laboratory blood and urine testing were evaluated.

RESULTS

The prostheses were implanted utilizing cemented stems in 5 patients and cementless stems in 5 patients. Intraoperatively, well congruency of a prosthesis with capitellum and radial notch of ulna was observed in all cases. All patients had improvement of ROM, VAS score, DASH score, and MEPS during the postoperative follow-ups. At the final follow-up, mean elbow extension was 6.5° (range, 0°-30°), flexion 145° (range, 125°-150°), supination 79° (range, 70°-80°), and pronation 73.5° (range, 45°-80°). Mean VAS score was 0.3 (range, 0-3), DASH score was 12.35 (range, 1.7-23.3), and MEPS was 99.5 (range, 95-100). Postoperative radiographs demonstrated heterotopic ossification in 2 cases, periprosthetic radiolucency in 2 cases, and proximal radial neck resorption in 2 cases. No one had the evidence of capitellar erosion, implant failure, malpositioning, overstuffing, or symptomatic stem loosening. There was no significant alteration of laboratory results or adverse events related to the 3D-printed prosthesis implantation.

CONCLUSION

The preliminary results demonstrated that implantation of the 3D-printed patient-specific titanium RH prosthesis is safe and may be a potential treatment option for irreparable RH fracture.

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.

Non-operative Treatment of Mason Type I Radial Head Fractures: A Comparative Analysis Using Patient-Reported Outcomes Measurement Information System (PROMIS)

OBJECTIVES

The purpose of this study is to compare the outcomes of Mason type I radial head fractures. This information will help to provide physicians with a critical decision-making tool when considering non-operative intervention and evaluate Patient-Reported Outcomes Measurement Information System (PROMIS) as a potentially valuable measure to track outcomes.

METHODS

We retrospectively identified 527 patients undergoing non-operative intervention. Demographic information, physical exam measurements, patient acceptable symptom state (PASS), and PROMIS Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) scores were analyzed over 12 months.

RESULTS

At the initial outpatient post-injury visit (within one week of injury), the average PROMIS PF, UE, PI, and Depression were 42.04 (SD: 6.3), 35.31 (SD: 7.3), 59.18 (SD: 9.2), and 48.68 (SD: 6.8), respectively. The average change in PROMIS PF, UE, PI, and Depression scores from the time of injury to six weeks were -0.23 (p=0.7), 1.43 (p=0.03), -2.1 (p=0.01), and -0.99 (p=0.1). The average change in PROMIS PF, UE, PI, and Depression scores from the time of injury to six months was -0.56 (p=0.56), 1.84 (p<0.001), -1.84 (p<0.001), and -0.13 (p=0.68). Among patients initially reporting "not acceptable" on PASS and reporting "acceptable" at the six-month visit, the average PROMIS PF, UE, PI, and Depression scores were 42.14, 38.91, 56.91, and 47.51 respectively. This represents an average difference of 1.11 (p=0.07), 2.82 (p<0.01), -1.19 (p=0.04), and -1.7 (p=0.01) respectively.

CONCLUSION

PROMIS UE and PI significantly improved among Mason I radial head fractures treated non-operatively at both six-week and six-month follow-up points but did not meet the mean clinically important difference (MCID) PROMIS PF did not significantly differ between the time of injury, six-week or six-month follow-up points. Only PROMIS UE correlated with PASS at six-week and six-month follow-up. Among patients who improved from negative to positive responses on PASS, PROMIS UE, and PI significantly improved.

A salvage procedure: Radial head excision in children and adolescents-short-to-midterm outcomes and overview of the literature

Purpose

Purpose of the study was to report the outcomes after radial head excision in children and adolescents in addition with a review of the current literature.

Methods

We report a series of five children and adolescents, who had undergone a post-traumatic radial head excision. Clinical outcomes were evaluated in terms of elbow/wrist range of motion, stability, deformity and discomforts or restrictions at two follow-up points. Radiographic changes were evaluated.

Results

Patient's age at time of the radial head excision averaged 14.6 (13-16) years. Mean time from the injury to the radial head excision was 3.6 (0-9) years. Follow-up I averaged 4.4 (1-8) years and follow-up II 8.5 (7-10) years. At follow-up I, patients showed an average elbow range of motion of 0-10-120° Ext/Flex and 90-0-80° Pro/Sup. Two patients reported discomfort or pain at the elbow. Four (80%) patients had a symptomatic wrist with pain or crepitation at the distal radio ulnar joint. In three (60%) of them, an ulna plus at the wrist was present. Two patients required ulna shortening and autograft stabilization of the interosseous membrane. At final follow-up, all patients reported full functioning with daily activities. Restrictions were present with sport activities.

Conclusion

Functional results at the elbow joint might be improved and pain syndromes lessen due to the radial head excision. Problems at the wrist are likely secondary to the procedure. A critical analysis of other options should be performed ahead of the procedure and a careless application should be avoided by all means.

Level of evidence

IV.

Acute versus delayed radial head arthroplasty for the treatment of radial head fractures

BACKGROUND

Radial head arthroplasty (RHA) is an important tool in the acute treatment of comminuted radial head and neck fractures. RHA is also performed in a delayed manner after failed open reduction and internal fixation, for fracture malunion or nonunion, and other chronic post-traumatic elbow disorders where restoration of the lateral column of the elbow is considered necessary. The relative efficacy and longevity of acute vs. delayed RHA is unknown. We sought to compare clinical, radiographic, and patient-reported outcomes between these groups.

METHODS

We identified patients ≥18 years old who underwent an RHA between 2000 and 2018 and then extracted 135 total elbows with a mean follow-up of 2.3 years that sustained isolated radial head fractures (30%), terrible triad injuries (66%), or Essex-Lopresti injuries (4%). The acute cohort (RHA: <12 weeks) contained 101 elbows that underwent surgery at a mean of 0.6 weeks (range, 0 days to 7 weeks, 96% <2 weeks) from injury, whereas the delayed cohort (RHA: 12 weeks to 2 years) contained 34 elbows that underwent surgery at a mean of 36 weeks (range, 14-82 weeks) from injury. Patients in the acute group had a higher percentage of terrible triad injuries (75% vs. 40%, P < .001) and Mason 3 fractures (98% vs. 45%, P < .001).

RESULTS

At the final follow-up, 13 of 101 patients in the acute cohort (13%) and 7 of 34 patients in the delayed cohort (21%) required implant revision or resection. A total of 25 patients (25%) in the acute cohort and 12 patients (35%) in the delayed cohort required a reoperation. Kaplan-Meier 2-year survival estimates free of implant resection or revision (90% acute, 86% delayed) and reoperation (76% acute, 70% delayed) were similar between groups. In patients with 5-year follow-up, there was an increased rate of revision or resection in the delayed group (30% vs. 13%). Two-year survival estimates free of radiographic loosening were 80% in the acute cohort vs. 57% in the delayed cohort (P = .04). Mayo Elbow Performance Score at 2 years demonstrated mean scores of 83 and 79 in the acute and delayed groups, respectively, with 71% of the acute cohort and 64% of the delayed cohort achieving good or excellent scores.

CONCLUSIONS

Our results demonstrated that although 2-year Kaplan-Meier survival free of revision or resection estimates and reoperation rates was equivalent between the groups, the delayed group experienced worse Mayo Elbow Performance Score outcomes, a higher revision or resection rate at 5 years, and an increased rate of radiographic loosening.

A systematic review and meta-analysis on different stem fixation methods of radial head prostheses during long-term follow-up

Background: Radial head arthroplasty (RHA) is typically performed for non-reconstructible radial head fractures with or without valgus stability. The fixation methods can be divided into cemented rigid fixation, such as screw fixation, and uncemented micromovement fixation, including smooth stem, press-fit, expanded device, in-growth stem, and grit-blasted stem fixations. Different fixation methods may impact long-term clinical outcomes and cause complications. This study aimed to compare the long-term follow-up outcomes of cemented and uncemented radial head prostheses. Methods: A computerized literature search was performed in the PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science databases for studies on radial head prostheses, replacement, and arthroplasty published from inception to April 2022. The prostheses fixation method was divided into cemented and uncemented fixation groups. The outcomes of interest included the participant characteristics, prostheses types, clinical outcomes, reoperation rates, and complication rates during long-term follow-up. Results: A total of 57 studies involving 2050 patients who underwent RHA were included in our analysis. Cemented fixation was used in 23 of these studies, uncemented fixation in 35 studies, and both cemented and uncemented fixations in one study. Both fixation groups showed significantly improved clinical outcomes after treatment. In particular, both the reoperation and complication rates were lower in the uncemented fixation group (12% and 22%, respectively) than that in the cemented fixation group (20% and 29%, respectively). Among the studies, uncemented monopolar fixation had the lowest reoperation rate (14%), while cemented monopolar fixation had the highest reoperation rate (36%). Regarding complication rates, uncemented bipolar fixation yielded the lowest rate (12%), while cemented bipolar fixation yielded the highest rate (34%). The range of motion and clinical outcome scores were good in both groups. Conclusion: Uncemented radial head prostheses had lower reoperation and complication rates than cemented prostheses. In particular, uncemented monopolar prostheses may yield the lowest reoperation rate, while uncemented bipolar prostheses may yield the lowest overall complication rate.

Comparative Study Between the Mini-Open (≤2.5 Cm) Approach and Conventional Open Lateral Approach in the Surgical Treatment of Radial Head Fractures

Purpose

The conventional lateral approach is widely used to treat radial head fractures with screws. However, the traditional incision may have shortcomings, including excessive exposure and significant scarring. We propose an innovative method – a mini-open lateral approach of less than 2.5 cm for surgical treatment of radial head fractures with screws.

Methods

From Jan 2017 to Dec 2020, 34 patients diagnosed with closed radial head fracture were treated with open reduction and internal fixation (ORIF) in this study. The novel group (mini-open group) included 15 patients, and the other 19 patients were in the traditional group. The time of operation and the blood loss during operation were recorded. Postoperative clinical outcomes and radiographic results were recorded and compared between the two groups. The range of motion (ROM) in the elbow, the Visual Analogue Scale (VAS), the Mayo Elbow Performance Score (MEPS), Rating Scale of the American Shoulder and Elbow Surgeons (ASES), and the Shortened Disabilities of the Arm, Shoulder and Hand Questionnaire (Q-DASH) score and complications, such as wound infection, vascular and nerve damage, and fragment redisplacement were observed in the two groups.

Results

In the comparison between the two groups, there was no significant difference in age, sex, cause of radial head fracture, or other basic information. The operation time, intraoperative blood loss, and VAS score at 3 days postoperation were significantly reduced in the novel group (p < 0.05). The follow-up results showed that there was no significant difference in MEPS, ASES, or Q-DASH scores between the two groups.

Conclusion

The mini-open approach reduced intraoperative blood loss, shortened operation time, relieved patient pain, and achieved a satisfactory postoperative clinical result, which demonstrates that the novel approach is a safe and effective option for treating radial head fractures.

Survivorship of anatomic press-fit short-stem radial head replacement with a pyrocarbon bearing

BACKGROUND

Restoring the radial head as a stabiliser of the elbow is considered important in cases where there is an associated bony or ligamentous injury. A variety of radial head prostheses are available. There are no reports of the survivorship of a short-stem press-fit radial head prostheses with pyrocarbon bearing.

PATIENTS AND METHODS

With institutional review board approval, a retrospective case-note analysis was performed of a consecutive single-surgeon case series of the Integra LifeScience pyrocarbon radial head prostheses (Carbon Modular Radial Head) from October 2010 to October 2019 in a tertiary referral centre. The series was divided into acute trauma and salvage cohorts. Kaplan-Meier survivorship analysis was conducted.

RESULTS

36 patients were included, 23 (64%) for acute injuries and 13 (36%) for failed initial treatment. Of the acute injuries, 20 (87%) had a Wrightington type-C elbow fracture-dislocation. Reoperation was performed in 4 (11%) patients; 10 (28%) had possible loosening on radiographs. The implant survival rate was 94% at shortest follow-up of 17 months (mean 70 months).

DISCUSSION

Treatment of complex radial head fractures using a pyrocarbon-bearing, anatomic press-fit design provides satisfactory short-term survivorship in this case series. The implant should be used with caution in salvage cases, due to higher rates of loosening seen in this cohort.

Functional outcomes and complications following convertible primary total elbow arthroplasty: A single surgeon series

BACKGROUND

The data on convertible total elbow arthroplasty are limited and primarily based on multiple centre/multiple surgeon series. The aim of this study was to report the mid-term functional outcomes, radiological findings, complications and survivorship of the Latitude total elbow arthroplasty performed by a single surgeon.

STUDY DESIGN & METHODS

The study included 13 patients (10 females, mean age of 72 years and varying indications) over eight years. The Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPS), range of movements (ROM), Subjective Elbow Value (SEV), satisfaction score (SS) and the revision rate of the implant per 100 observed component years (OCY) were assessed.

RESULTS

The mean follow-up was 5.9 years (3-10 years). The Oxford Elbow Score/Mayo Elbow Performance Score improved from 15 to 42 (p value < 0.005)/26% to 93% (p value < 0.005) respectively. The arc of extension-flexion/supination-pronation improved from 63° to 106° (p = 0.00002)/123° to 142° (p = 0.32) respectively. The Subjective Elbow Value/Satisfaction Score was 83/98 respectively. There was one re-operation for a deep infection. There were no radiologic signs of loosening and the revision rate was 0.15 per 100 observed component years.

CONCLUSIONS

With careful patient selection, convertible total elbow arthroplasty provides patients with good to excellent outcomes and substantial improvements in the range of movements.

Anatomic Radial Head Arthroplasty: The Importance of Implant Angle

PURPOSE

Multifragmentary radial head and neck fractures not amenable to open reduction and internal fixation are usually treated with radial head arthroplasty (RHA). Although the optimal implant design is still subject to debate, anatomic designs are common. We hypothesized that positioning of the implant leading to increased radial stem angle (RSA) (angle of the RHA stem with respect to the proximal radius shaft, RSA) in anatomic RHA designs will contribute to failures. The aim of this study was to characterize the risk of RHA failure with respect to the stem angle in anatomic RHA design.

METHODS

A retrospective review of patients who underwent anatomic RHA for acute fractures between 2006 and 2019 at 2 academic centers was conducted. Initial postoperative elbow radiographs were reviewed to measure RSA on the anterior-posterior and lateral views. Radiolucency, stress shielding, and radiocapitellar arthritis were also evaluated. Implant failure was defined as prosthesis removal or revision.

RESULTS

Implant failure was associated with significantly larger lateral RSA than that in intact implants. Increasing stem shaft angle on a lateral radiograph was associated with decreased implant survival. Radiolucency, stress shielding, and radiocapitellar arthritis were similar between the 2 groups.

CONCLUSIONS

Anatomic radial head implants are commonly used; however, the importance of prosthesis positioning, specifically that of the stem within the proximal radius, remains understudied. Higher RSA is associated with the risk of implant failure and need for revision.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

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).

Outcomes of radial head implants in total elbow arthroplasty

BACKGROUND

There is no consensus on the management of the radial head in total elbow arthroplasty (TEA). In 3-part TEA designs, options include radial head retention, excision, or arthroplasty. Biomechanical studies suggest improved varus-valgus stability with radial head implants in unlinked total elbows. Unfortunately, complications with radial head implants have been common with historical designs. The aim of this study was to evaluate the clinical and radiographic outcomes of radial head implants in a current 3-part TEA and identify risk factors for mechanical failure.

METHODS

We performed a retrospective review of radial head implants with a 3-part convertible TEA from 2001 to 2016. Clinical outcomes, functional scores, and radiographic outcomes were recorded. The preoperative radiocapitellar alignment was measured using the radiocapitellar ratio (RCR). Statistics include descriptive statistics, t tests, logistic regression, and Kaplan-Meier survival curves.

RESULTS

We identified 44 TEAs in 40 patients, with a mean follow-up period of 7.2 years. The average age at surgery was 58 ± 11 years; 80% of the TEAs were performed in women. The indication for surgery was rheumatoid arthritis in 86%; of the implants, 61% were unlinked. The average preoperative RCR was 10.7 ± 17.9. Postoperatively, 2 radial head implants (5%) were subluxated, 6 (14%) were dissociated, and 2 (5%) were dissociated with implant dislocation on radiographic review. The revision rate for radial head subluxation, dissociation, or dislocation was 7% (n = 3). Univariate logistic regression showed that male sex (P = .002), abnormal preoperative RCR (P = .02), linked implant (P = .03), and older age (P = .04) were risk factors for radial head subluxation, dissociation, or implant dislocation. A multivariate model with all 4 variables did not demonstrate statistical significance.

CONCLUSION

The incidence of radial head arthroplasty subluxation, dissociation, or implant dislocation was high (23%). In a univariate logistic regression model, male sex, abnormal preoperative RCR, and linked implants were all statistically significant risk factors for mechanical failure of the radial head implant. Our multivariate model did not show any statistically significant independent risk factors. Polyethylene wear or loosening of the radial head implants was not observed in this study; failure of the bipolar linkage was the principal mode of failure. Although further study is required, caution should be used when considering inserting a radial head implant in male patients with significant preoperative radiocapitellar malalignment. Radial head subluxation or dissociation is not an absolute indication for revision in an asymptomatic patient. Improvements in radial head implant designs in TEA are needed.

Delayed anterolateral radial head dislocation secondary to radial shaft fracture malunion: A case report

RATIONALE

Traumatic radial head dislocation (RHD) can occur due to hyperpronation injury with sequential disruption of the annular ligament, quadrate ligament, and the interosseous membrane. Although studies have shown that traumatic RHD is generally associated with Monteggia fracture-dislocation, traumatic RHD occurring with ipsilateral radial shaft fractures has rarely been reported. Delayed RHD secondary to the malunion of isolated radial shaft fractures is extremely rare.

PATIENT CONCERNS

We report the case of a 12-year-old right-handed boy with progressive pain and limited range of motion in the right elbow.

DIAGNOSIS

The patient was diagnosed with delayed RHD associated with radial shaft fracture malunion.

INTERVENTIONS AND OUTCOMES

A corrective osteotomy was performed at the site of malunion with open reduction of the radial head using an extensile lateral approach. The annular ligament was disrupted. Forearm rotation causes radial head subluxation Therefore, the Bell Tawse procedure was additionally performed to reconstruct the annular ligament by turning down a strip of triceps tendon and anchoring it around the radial neck.

LESSONS

Malunion of the radial shaft can cause delayed RHD with a limited elbow range of motion. Annular reconstruction using a strip of the triceps tendon and corrective osteotomy of the radial shaft with an extensile lateral approach may be useful for treating this rare entity or situation.

Computed tomography analysis of the relationship between the coronoid and the radial head

BACKGROUND

The coronoid process is an important stabilizer of the elbow, and its anatomy has been extensively studied. However, data documenting the relationship of the coronoid relative to the radial head (RH) are limited. The latter is a good landmark for the surgeon when débriding or reconstructing the coronoid. This imaging-based study quantified the anatomic relationship between the coronoid and the proximal radius and ulna.

METHODS

We investigated 80 cadaveric upper extremities (18 paired elbows) by 3-dimensional digital analysis of computed tomography data. After construction of a standardized coordinate system, the relationships between the coronoid, the anterior-most point of the RH, the deepest point of the articular surface of the RH, the top of the lesser sigmoid notch, and the deepest point of the guiding ridge of the trochlear notch were analyzed.

RESULTS

The mean height of the tip of the coronoid was 36 ± 4 mm (range, 26-43 mm). The mean height of the anterior-most point of the RH was 40 ± 4 mm (range, 28-47 mm). The mean distance between the tip of the coronoid and the anterior-most point of the RH was 4.5 ± 1 mm (range, 2-10 mm). For paired elbows, the heights of the tip of the coronoid and the anterior-most point of the RH were similar between sides.

CONCLUSION

This study described the relationship between the coronoid and RH. This information should prove useful when reconstructing a coronoid from a medial approach in the case of an intact RH. The difference in radiographic height between the tip of the coronoid and anterior RH in the normal elbow averages 5 mm. However, when we account for the normal cartilage thickness of the RH and coronoid, a 3- to 6-mm difference in height would be seen at surgery depending on whether the cartilage of the coronoid process is intact or removed. The distance between the tip of the coronoid and the anterior-most point of the RH is similar to the size of shavers used when débriding osteophytes during arthroscopy.

Lateral minimal approach to the terrible triad of the elbow: a treatment protocol in Beijing Jishuitan Hospital

Background

This study aimed to report the surgical techniques and results of treating coronoid process and radial head fracture combined with dislocation of the elbow (terrible triad of the elbow) using a single lateral incision, known as the extensor digitorum communis (EDC) split approach.

Methods

A retrospective analysis was performed of 109 patients with terrible triad of the elbow who had been treated by the authors from January 2013 to December 2019. The participants included 67 males and 42 females, with a mean age of 42.2 years (14–71 years). All participants were treated via a single lateral approach. The coronoid process was fixated with Kirschner wires combined with anterior capsule suture lasso fixation. For the radial head fracture, 58 cases were fixated by AO headless cannulated screw (AO HCS) and 51 cases by acumed radial head replacement. In repair of the lateral collateral ligament (LCL) complex and the common extensor tendon, 28 cases used ETHIBOND suture through bone holes at the humeral lateral epicondyle, and the other 81 cases used suture anchors. No medial collateral ligament was repaired. A total of 46 participants were fixated with a Stryker dynamic joint distractor (DJD) II hinged external fixator to protect the bone and soft tissue.

Results

All participants were followed up from 6 to 60 months (mean, 36.1 months). Their elbow range of flexion and extension averaged 123.4°±20.7°, forearm rotation 151.0°±25.6°, and Mayo elbow performance score (MEPS) 92.3±8.8. There were 22 participants (19.5%) with ulnar nerve symptoms, 16 (14.7%) who had elbow stiffness, and 7 underwent secondary surgery, including 6 removals of internal fixation, 5 arthrolyses of the elbow, and 2 ulnar neurolyses.

Conclusions

Coronoid fractures, radial head fractures, and LCL injuries of the terrible triad of the elbow can be treated satisfactorily through a lateral minimal incision, combined with a hinged external fixation if necessary.

Analysis of Fracture Characteristic and Medial Collateral Ligament Injury Relationships in Terrible Triad Elbow Injuries

PURPOSE

The objectives of this study were to identify the relationship between fracture characteristics and medial collateral ligament (MCL) injuries in terrible triad injuries of the elbow.

METHODS

Between 2010 and 2018, 60 patients who underwent surgery for terrible triad elbow injuries were retrospectively reviewed. Using magnetic resonance imaging (MRI) assessments, patients were stratified into those who had intact or low-grade partial MCL tears (low-grade MRI-MCL group) and those who had high-grade partial or full-thickness MCL tears (high-grade MRI-MCL group). We also analyzed patients according to whether they underwent MCL repair surgery. Fractures of the radial head were assessed according to Mason's classification system and measurements of fracture fragment arc on axial cuts. Fractures of the coronoid processes were assessed according to the system of Regan and Morrey and measurements of coronoid process volumes.

RESULTS

Patients in the high-grade MRI-MCL group (28 patients) had a more comminuted and higher fragment arc of radial head fractures than those in the low-grade MRI-MCL group (32 patients) (143º ± 45º vs 119º ± 31º). However, the volume of coronoid fracture fragments was smaller in the high-grade MRI-MCL than in the low-grade MRI-MCL group (359 ± 325 mm³ vs 722 ± 448 mm³). The MCL repair group (22 patients) also had a more comminuted and higher fragment arc in radial head fractures (153º ± 44º vs 117º ± 31º) and a smaller coronoid process fracture volume (236 ± 224 mm³ vs 735 ± 419 mm³) than the non-MCL repair group (38 patients).

CONCLUSIONS

Our results demonstrated that high-grade MCL injuries are associated with comminuted and larger-sized radial head fractures, as well as smaller-sized coronoid process fractures in terrible triad injuries. In making a decision regarding surgical treatment, these fracture characteristics could help to predict the severity for MCL injury in terrible triad injuries.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

[Comparison of two techniques for lateral collateral ligament complex repair in treatment of terrible triad of elbow]

Objective

To compare the effectiveness of transosseous tunnel fixation and drilling fixation for repair of lateral collateral ligament complex (LCLC) in treatment of terrible triad of elbow (TTE).

Methods

A clinical data of 50 patients with TTE between June 2012 and January 2018 were retrospectively analyzed. The LCLC was repaired with transosseous tunnel fixation in 22 patients (transosseous tunnel fixation group) and with drilling fixation in 28 patients (drilling fixation group). There was no significant difference between the two groups ( P>0.05) in gender, age, fracture side, time from injury to admission, coronoid process fracture classification, radial head fracture classification, and TTE classification. The operation time, intraoperative blood loss, fracture healing time, and complications of the two groups were recorded. At last follow-up, the Mayo elbow performance system (MEPS) score, range of motion of elbow joint, and Broberg-Morrey classification were recorded.

Results

The operation of two groups were successfully completed. There was no significant difference in the operation time and intraoperative blood loss between the two group ( P>0.05). The follow-up time was (24.43±6.84) months in the transosseous tunnel fixation group and (21.55±6.16) months in the drilling fixation group, and the difference was not significant ( t=1.534, P=0.132). X-ray films showed that the coronoid process and radial head fractures in the two groups healed, and there was no significant difference in the healing time ( P>0.05). At last follow-up, there was no significant difference in the flexion-extension activity, rotation activity, MEPS score, and Broberg-Morrey grading ( P>0.05). During the follow-up, there was no re-dislocation or instability of the elbow joint. The incidence of complication was 28.57% (8/28) in the transosseous tunnel fixation group and 27.27% (6/22) in the drilling fixation group, showing no significant difference ( χ ²=2.403, P=0.121).

Conclusion

Both transosseous tunnel fixation and drilling fixation can achieve good results in repair of LCLC for TTE.

Single oblique osteotomy for correction of congenital radial head luxation with concurrent complex angular limb deformity in a dog: a case report

A 5-month old Shih Tzu was diagnosed with congenital elbow luxation and uniapical complex angular deformity of the radius. Single radial oblique and dynamic ulnar osteotomies were performed, using patient-specific 3D-printed osteotomy guide. External skeletal fixation was maintained for three weeks to prevent re-luxation of elbow joint. Three months after the surgery, objective gait analysis indicated markedly improved limb function. In addition, radiograph showed improved congruity of elbow joint and appropriate bone healing. In dogs with congenital radial head luxation and concurrent complex angular deformity, a single oblique osteotomy might be a viable option to preserve bone length and correct the luxation of elbow joint.

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

Effect of ulnar angulation and soft tissue sectioning on radial head stability in anterior Monteggia injuries: an in vitro biomechanical study

BACKGROUND

Radial head instability continues to be a challenge in the management of anterior Monteggia injuries; however, there is a paucity of literature on the factors that contribute to this instability. The aim of this biomechanical investigation was to examine the effects of ulnar angulation and soft tissue insufficiency on radial head stability in anterior Monteggia injuries.

METHODS

Six cadaveric arms were mounted in an elbow motion simulator. Radial head translation was measured during simulated active elbow flexion with the forearm supinated. After testing the elbows in the intact state, the ulna was osteotomized and tested at 0°, 10°, 20°, and 30° of extension angulation. To examine the effect of soft tissue insufficiency, the anterior radiocapitellar joint capsule, annular ligament, quadrate ligament, and the proximal and middle interosseous membrane (IOM) were sequentially sectioned.

RESULTS

There was a significant increase in anterior radial head translation with greater ulnar extension angulation. Sequential soft tissue sectioning also significantly increased anterior radial head translation. There was no increase in radial head translation with isolated sectioning of the anterior radiocapitellar joint capsule. Additional sectioning of the annular ligament and quadrate ligament slightly increased anterior radial head translation but did not reach statistical significance. Subsequent sectioning of the proximal and middle IOM resulted in significant increases in anterior radial head translation.

CONCLUSION

Our study demonstrates that progressive ulnar extension angulation results in an incremental increase in anterior radial head translation in anterior Monteggia injuries. Moreover, increasing magnitudes of soft tissue disruption result in greater anterior radial head instability.

Indications and outcomes of radial head excision: A systematic review

BACKGROUND

Radial head excision has historically been a common surgical procedure for the operative management of radial head fractures and post-traumatic conditions. With recent advances in other surgical techniques, controversy exists regarding its indications. This review evaluates the indications and outcomes of radial head excision in traumatic and non-traumatic elbow pathology.

METHODS

Multiple databases were searched for studies involving radial head excision. Screening and data abstraction were conducted in duplicate. Only studies reporting outcomes for radial head excision were included.

RESULTS

Twenty-seven studies with 774 radial head excision patients were included. The most common indications involved acute excision of comminuted radial head fractures (n = 347) and rheumatoid arthritis (n = 201). Post-operative functional scores after acute excision were reported to be good to excellent. In the chronic setting of rheumatoid disease, radial head excision resulted in improved range of motion, although pain was not effectively relieved.

DISCUSSION

Outcomes of radial head excision for acute fracture are good to excellent; however, it should not be performed when concurrent or ligamentous injuries are present. Although some studies compared excision to open reduction and internal fixation or replacement, more data are needed to make proper conclusions. The strength of these conclusions is limited by the quality of included literature.

Radial head fractures

The shape and size of the radial head is highly variable but correlates to the contralateral side. The radial head is a secondary stabilizer to valgus stress and provides lateral stability. The modified Mason-Hotchkiss classification is the most commonly used and describes three types, depending on the number of fragments and their displacement. Type 1 fractures are typically treated conservatively. Surgical reduction and fixation are recommended for type 2 fractures, if there is a mechanical block to motion. This can be done arthroscopically or open. Controversy exists for two-part fractures with >2 mm and <5 mm displacement, without a mechanical bloc as good results have been published with conservative treatment. Type 3 fractures are often treated with radial head replacement. Although radial head resection is also an option as long-term results have been shown to be favourable. Radial head arthroplasty is recommended in type 3 fractures with ligamentous injury or proximal ulna fractures. Failure of primary radial head replacement may be due to several factors. Identification of the cause of failure is essential. Failed radial head arthroplasty can be treated by implant removal alone, interposition arthroplasty, revision radial head replacement either as a single stage or two-stage procedure.

Matching precision of the reverse contralateral radial head in generating of the individualized prosthesis from the surface registration in tuberosity-neck and in tuberosity-diaphysis

PURPOSE

Following the radial head replacement, the surface mismatches between the implants and the morphological characteristics of the original proximal radius decreased contact areas and increased contact forces which is potential for the long-term articulating cartilage wear. Several studies demonstrated that the individualized prosthesis, created from computed tomographic (CT) images of the contralateral side with the reverse engineering technology, may reduce the mismatch. The aim of this study is to demonstrate the matching precision of the reverse contralateral head between the surface registration in tuberosity-neck (TN) area and in tuberosity-diaphysis (TD) area.

MATERIALS AND METHODS

High-resolution CT scan of 11 pairs of the cadaveric arms was performed. Utilizing advanced image processing techniques, three-dimensional (3-D) models of each specimen was generated. The model of the left side was reversed and matched with the model of the right side in the same cadaver by registering in the area of radial neck along with tuberosity (TN) and in the area of radial tuberosity combined with 2 cm of proximal diaphysis (TD). The alteration of the head diameter, dish diameter, articular depth, head thickness, end-plane angle, offset, and head volume were evaluated and analyzed by paired t-test.

RESULTS

No statistically significant difference was found in all parameters from both TN and TD registrations ( p < 0.05).

CONCLUSION

The surface registration in either TN or TD area can generate the statistically symmetrical 3-D model with the original head. The registration in these areas may possibly be used in creating the individualized radial head prosthesis.

Isolated Radial Shaft Fracture with Unreducable Posterior Dislocation of the Radial Head in Adult: A Case Report

INTRODUCTION

Isolated fracture of the radial diaphysis with dislocation of the radial head is a rare injury, which requires careful evaluation. Combined injuries associated with forearm shaft fractures and elbow dislocations are well recognized.

CASE REPORT

A 35-year-old male presented to our emergency department with a history of fall in ditch under influence of alcohol with swelling of her right elbow and deformity of right upper limb. Roentgenograms showed oblique fracture of the radial shaft and dislocation of radial head posteriorly. He underwent open reduction and internal fixation of fracture with limited contact dynamic compression plate and reduction of radial head and fixing with radiocapitellar wire. After 4 months, the fracture healed fully and he had complete full range of elbow movements.

CONCLUSION

Ipsilateral radial head dislocation and radial shaft fracture are extremely rare injury in a child. A good outcome can be achieved by applying principles of the management of proximal forearm fracture-dislocation. Ipsilateral radial head dislocation and radial shaft fracture is extremely rare injury in a child. A good outcome can be achieved by applying principles of management of proximal forearm fracture-dislocation.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A biomechanical study of headless compression screws versus a locking plate in radial head fracture fixation

HYPOTHESIS

Fixation of a 3-part radial head fracture with cannulated compression screws will show equivalent stiffness to a locking plate under axial load. Debate exists regarding the management of Mason type III fractures, with many believing that open reduction and internal fixation provides advantages over other options. By virtue of their subarticular placement, screw fixation is less likely to cause impingement compared with plate fixation, which can result in loss of rotation and requirement for hardware removal. Insufficient fixation stability can lead to nonunions, necrosis of the radial head, pain, and instability. We tested the mechanical stability of fixation of simulated radial head fractures using headless compression screws compared with standard plate construct.

METHODS

Standardized test constructs were created with repeatable osteotomy cuts and hardware placement on each Synbone model (Synbone AG, Malans, Switzerland). We presectioned 22 proximal radius Synbone models to simulate a 3-part radial head fracture. The models were fixed using a radial head locking plate or headless compression screws in a tripod construct. The constructs were potted into a compression test jig using 2-part epoxy resin. Compression testing was performed using a 30-kN Instron Universal machine (Instron, Norwood, MA, USA). The compression tool was spherical, representing the surface of the capitellum.

RESULTS

There was no significant difference between the stiffness of the Synbone constructs under axial load.

CONCLUSION

There was no significant difference between fixation stiffness of a 3-part radial head fracture with headless compression screws in a tripod structure vs. a locking plate in Synbone. Further study is required to allow clinical application.

Comparison of Exposure in the Kaplan Versus the Kocher Approach in the Treatment of Radial Head Fractures

BACKGROUND

The aim of this study was to compare the complete visible surface area of the radial head, neck, and coronoid in the Kaplan and Kocher approaches to the lateral elbow. The hypothesis was that the Kaplan approach would afford greater visibility due to the differential anatomy of the intermuscular planes.

METHODS

Ten cadavers were dissected with the Kaplan and Kocher approaches, and the visible surface area was measured in situ using a 3-dimensional digitizer. Six measurements were taken for each approach by 2 surgeons, and the mean of these measurements were analyzed.

RESULTS

The mean surface area visible with the lateral collateral ligament (LCL) preserved in the Kaplan approach was 616.6 mm² in comparison with the surface area of 136.2 mm² visible in the Kocher approach when the LCL was preserved. Using a 2-way analysis of variance, the difference between these 2 approaches was statistically significant. When the LCL complex was incised in the Kocher approach, the average visible surface area of the Kocher approach was 456.1 mm² and was statistically less than the Kaplan approach. The average surface area of the coronoid visible using a proximally extended Kaplan approach was 197.8 mm².

CONCLUSIONS

The Kaplan approach affords significantly greater visible surface area of the proximal radius than the Kocher approach.

[Congenital radial head dislocation: report of two cases]

INTRODUCTION

Congenital dislocation of the Radial head is a condition that has been described in a few cases in the international literature, the anterior and lateral dislocation were the less frequent forms of presentation with 15% of cases, each, and the posterior dislocation the most frequent with 70% of the total cases reported. However, this pathology is considered the most frequent congenital pathology of the elbow in children. The present study describes the case of a patient with congenital dislocation of elbow anterior variety and another case with dislocation lateral variety, both diagnosed at an early age, in which it has been decided for conservative management and an annual follow-up. A bibliographic review of the subject is also carried out.

DISCUSSION

The congenital elbow dislocation usually has a benign evolution, being painless and not very limiting for the patient, so it can be managed conservatively. Pain and limited movement are indicative of surgical treatment. There are multiple surgical treatments for this entity, however they are not widely accepted due to the complications and poor results presented by them.

Fractures of the proximal ulna: current concepts in surgical management

Fractures of the proximal ulna range from simple olecranon fractures to complex Monteggia fractures or Monteggia-like lesions involving damage to stabilizing key structures of the elbow (i.e. coronoid process, radial head, collateral ligament complex).

In complex fracture patterns a computerized tomography scan is essential to properly assess the injury severity.

Exact preoperative planning for the surgical approach is vital to adequately address all fracture parts (base coronoid fragments first).

The management of olecranon fractures primarily comprises tension-band wiring in simple fractures as a valid treatment option, but modern plate techniques, especially in comminuted or osteoporotic fracture types, can reduce implant failure and potential implant-related soft tissue irritation.

For Monteggia injuries, the accurate anatomical restoration of ulnar alignment and dimensions is crucial to adjust the radiocapitellar joint.

Caution is advised if the anteromedial facet (anatomical insertion of the medial collateral ligament) of the coronoid process is affected, to avoid posteromedial instability.

Radial head reconstruction or replacement is essential in Monteggia-like lesions to restore normal elbow function.

The postoperative rehabilitation programme should involve active elbow motion exercises without limitations as early as possible following surgery to avoid joint stiffness.

Cite this article: EFORT Open Rev 2019;4:1-9. DOI: 10.1302/2058-5241.4.180022.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of radiocapitellar Achilles disc arthroplasty on coronoid and capitellar contact pressures after radial head excision

BACKGROUND

Long-term radiographic arthritis has been commonly reported after radial head excision. Concern over radial head arthroplasty may arise in certain situations including capitellar arthritis, radiocapitellar malalignment, and in young and active patients. We hypothesized that radial head excision increases coronoid contact pressures, which may at least be partially reduced by radiocapitellar Achilles tendon disc arthroplasty.

METHODS

Coronoid and capitellar contact pressure was measured on 6 human cadaveric elbows on a custom-designed gravity-valgus simulator under passive flexion from 0° to 90°. Sequential testing, starting with the intact specimen, resection of the radial head, and finally, radiocapitellar Achilles tendon disc arthroplasty were performed on each specimen.

RESULTS

Mean contact pressure of the coronoid significantly increased after radial head excision (P < .0001) and significantly improved after Achilles disc arthroplasty (P < .0001). The pressure difference was most pronounced on the lateral coronoid. From 15° to 85° of elbow flexion, mean contact pressures on the lateral coronoid were 291 kPa and 476 kPa before and after radial head excision, respectively (P < .0001). Achilles disc arthroplasty significantly lowered coronoid contact pressures to 385 kPa (P = .002); however, they remained significantly higher than those in the intact radial head group (P = .0009).

CONCLUSIONS

Radial head resection increases contact pressure in the coronoid, especially the lateral coronoid. This study showed that radiocapitellar Achilles disc arthroplasty significantly improves contact pressures on the coronoid after radial head resection. Achilles disc arthroplasty could be considered in patients who are not candidates for radial head arthroplasty.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Interobserver reliability of radiographic assessment after radial head arthroplasty

BACKGROUND

Radiographs are part of routine clinical care after radial head arthroplasty (RHA). Therefore, the aim of this diagnostic study was to assess the interobserver reliability of radiographic assessment following RHA.

METHODS

Anteroposterior (AP) and lateral radiographs of 24 consecutive patients who underwent press-fit bipolar RHA were evaluated with respect to 14 parameters by 14 orthopaedic surgeons specializing in the elbow: shaft loosening (AP, lateral), subcollar bone resorption, nonbridging heterotopic ossification, capitellar erosion, capitellar osteopenia, implant size, ulnohumeral joint gapping, ulnohumeral joint degeneration, proximal radio-ulnar joint congruency, stem size, stem positioning (AP, lateral) and component dissociation or polyethylene wear of the head with increased angulation. Observer agreement was evaluated using the multirater kappa (κ) measure.

RESULTS

Nine of 14 parameters had poor interobserver agreement [κ = 0.0 to 0.20, confidence interval (CI) = 0.0 to 0.31). Four parameters had fair agreement: subcollar bone resorption (κ = 0.27, CI = 0.12 to 0.40), capitellar erosion (κ = 0.30, CI = 0.20 to 0.40), ulnohumeral joint degeneration (κ = 0.35, CI = 0.22 to 0.51) and stem positioning in AP view (κ = 0.24, CI = 0.14 to 0.36). One parameter had moderate agreement: nonbridging heterotopic ossification (κ = 0.47, CI = 0.31 to 0.64).

CONCLUSIONS

The overall interobserver reliability of radiographic assessment following press-fit bipolar RHA was poor among experienced elbow surgeons. Therefore, radiographic evaluation after RHA should be interpreted with caution when making treatment decisions.

Radial Head Changes in Osteochondritis Dissecans of the Humeral Capitellum

BACKGROUND

Osteochondritis dissecans (OCD) of the elbow has almost exclusively been described in the humeral capitellum, with only a small number of reports describing secondary osteochondral changes in the radial head.

HYPOTHESIS

The authors hypothesized that concomitant radial head lesions (RHLs) would be seen with capitellar OCD and that patients with RHLs would present with more advanced capitellar OCD lesions and would respond better to procedures restoring articular congruity.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 86 elbows from 82 patients (39 female patients; mean ± SD age, 13.8 ± 2.2 years; age range, 9.8-23.6 years) were treated for capitellar OCD and enrolled in a prospective registry. Clinical and radiographic data were compared between those with and without RHLs, with a median follow-up of 10.8 months (interquartile range, 6.2-17.1 months). Magnetic resonance imaging was used to characterize and measure RHLs and OCD lesions. Postoperative clinical results were compared between patients who underwent drilling and those who had osteochondral autograft transplantation surgery (OATS).

RESULTS

RHLs were present in 26 (30%) elbows-17 in the dominant arm. Edema was seen in 22 elbows; 17 had involvement of the anterior third of the radial epiphysis. Cysts were present in 4 elbows: 2 in the anterior third and 2 in the middle third. Blunting of the normal concave contour of the radial epiphysis was present in 10 elbows in the anterior third. Demographic and presenting clinical features were similar between those with and without RHLs. RHLs were more commonly seen in Nelson grade 4 OCD lesions (P = .04) as compared with elbows without RHLs. Elbows with RHLs that underwent OATS (n = 9) trended toward greater improvement in forearm range of motion (P = .058) and fewer persistent mechanical symptoms (P = .06) postoperatively as compared with elbows having RHLs that underwent drilling. There were no postoperative differences in elbows without RHLs that underwent OATS versus drilling.

CONCLUSION

RHLs were seen in one-third of elbows with capitellar OCD. Lesions predominantly occurred in the anterior RH in patients with more advanced capitellar lesions. Short-term clinical follow-up suggested greater improvement in range of motion and resolution of mechanical symptoms for patients with RHLs who were treated with OATS than with drilling.

Prospective study of surgical fixation of radial head fractures using cannulated headless compression screws for simple and complex radial head fractures

INTRODUCTION

Fixing the two-part Mason II radial head fracture using screws is becoming a popular practice. However, the screw fixation efficacy for three-part Mason III and IV fractures is controversial. The purpose of this study is to determine the effectiveness of using a uniform technique of headless compression screw fixation in simple, isolated Mason II and complex three-part Mason III and IV radial head fractures in terms of functional outcome, treatment efficiency and assessment of complications with the procedure.

METHODS

A prospective evaluation were performed on 31 adult patients with closed, non-pathological Mason II, III and IV radial head fractures sustained due to trauma and who underwent fixation using either two or three cannulated headless compression screws of 2.0 to 2.5 mm, and all patients were followed up for 2 years after the injury. They were divided into simple Mason II fracture group and complex three-part Mason III-IV fracture group. Operation time, time to discharge and radiological union were used as parameters for assessment of clinical outcome, while Mayo Elbow Performance Score, range of motion and complications were used to assess the functional outcomes.

RESULTS

Twelve cases of two-part simple fracture group and 18 cases of complex fracture group were identified. The mean age of 39 years is comparable between the two groups. Both groups had comparable days to union, mean hospital stay and operation time. In the simple fracture group, the mean Mayo Elbow Score was 97 (80-100), which is better than the complex fracture group score of 89 (75-100), p = 0.035. Both groups had no statistical difference in complication rates. All fractures united in our series. The mean range of motion for the simple fracture group was significant, with 133° ± 17.0° for flexion-extension arc, 85° ± 5° in pronation and supination as compared to the complex fracture group with 120° ± 20° flexion-extension arc, 69° ± 10° in pronation and 70° ± 8° in supination, p = 0.068.

CONCLUSION

Overall clinical and functional outcomes of this technique are satisfactory in both simple and complex fracture groups, with simple Mason II fracture group doing better than the complex three-part Mason III and IV fractures in terms of Mayo Elbow Score and range of motion. Screw fixation has the advantage of less periosteal stripping and less impingement compared to other fixation methods and also allows for flexible fixation in constrained areas. Headless compression screw fixation can be considered as a method of fracture fixation for both simple and complex three-part radial head fractures.

Radial head replacement with a bipolar system: an average 10-year follow-up

BACKGROUND

We report the long-term results of a cohort of patients after radial head replacement with a bipolar design and a smooth cementless stem at a mean follow-up of 10.4 years.

METHODS

Of 17 possible patients from a previous minimum 2-year follow-up study, 16 were available for review. Patients were assessed using clinical and radiographic examination and with standardized outcome measures. Range of motion, stability, and radiographic evaluation of implant loosening and joint degeneration were assessed. Comparisons were performed using the Wilcoxon signed rank test for unequal groups.

RESULTS

The average follow-up was 10.5 years (range, 8.5-12 years). The median visual analog scale was 1 (range, 0-5), Minnesota Elbow Performance Index was 93 (range, 70-100), and the Disabilities of the Arm, Shoulder and Hand was 7.5 (range, 0-53). Range of motion was decreased on the operative side compared with the nonoperative side for flexion/extension (P = .005) and pronation/supination (P = .015). Grip strength was decreased on the affected side (P = .045). No patients had elbow instability. Significant arthritic changes developed in 2 patients at the ulnohumeral joint. The median cantilever quotient was 0.4 (range, 0.30-0.50). Osteolysis in zones 1 to 7 was found in all but 2 patients. The median stem radiolucency was 0.5 mm (range, 0.2-0.9 mm). No reoperations occurred since our previous report. Implant survival in this cohort was 97%.

CONCLUSION

Bipolar radial head prosthesis with a smooth cementless stem effectively restores elbow stability and function after comminuted radial head fractures with or without concomitant elbow instability. Our study demonstrates excellent long-term implant survival.

What Injury Mechanism and Patterns of Ligament Status Are Associated With Isolated Coronoid, Isolated Radial Head, and Combined Fractures?

BACKGROUND

Isolated coronoid, isolated radial head, and combined coronoid and radial head fractures are common elbow fractures, and specific ligamentous injury of each fracture configuration has been reported. However, the osseous injury mechanism related to ligament status remains unclear.

QUESTIONS/PURPOSES

The objectives of this study were: (1) to determine what ligamentous injury patterns (medial or lateral collateral) and bone contusion patterns (medial or lateral) are associated with isolated coronoid, isolated radial head, and combined coronoid and radial head fractures; (2) to correlate the osseous injury mechanism based on these findings with isolated coronoid, isolated radial head, and combined coronoid and radial head fractures; and (3) to determine whether isolated and combined coronoid fractures have different fracture lines through the coronoid (tip or anteromedial facet), speculated to be caused by different injury mechanisms.

METHODS

Between June 2007 and June 2012, 100 patients with elbow fractures were included in the cohort, with 46 of these patients being excluded owing to incongruity for our surgical indication. Finally, 54 patients with surgically treated elbow fractures who had MRI preoperatively were assessed retrospectively. There were 17 elbows with isolated coronoid fractures, 22 with isolated radial head fractures, and 15 with combined coronoid and radial head fractures. Collateral ligament injury pattern and existence of distal humerus bone contusion were reviewed on MR images.

RESULTS

Patients with isolated radial head fractures were at greater risk of medial collateral ligament rupture compared with patients with isolated coronoid fractures (radial head only: 15 of 22 [68%]; coronoid only: three of 17 [18%]; odds ratio [OR], 10.0; 95% CI, 2.2-46.5; p = 0.002). Patients with isolated coronoid fractures had greater risk of lateral ulnar collateral ligament ruptures (coronoid: 16 of 17 [94%]; radial head: seven of 22 [32%]; OR, 3.5; 95% CI, 3.8-333.3; p < 0.001). The presence of radial head fractures was associated with the risk of lateral bone bruising (isolated radial head fracture: 32 of 37 [86%], isolated coronoid fracture: four of 17 [24%]; OR, 29.6; 95% CI, 5.2-168.9; p < 0.001). Medial bone bruising was only detected in isolated coronoid fractures (isolated coronoid fracture: 12 of 17 [71%], others: zero of 37 [0%]). All isolated coronoid fractures involved the anteromedial facet of the coronoid (17 of 17; 100%). However, combined coronoid and radial head fractures often involved the tip (13 of 15; 87%).

CONCLUSIONS

Isolated coronoid fractures mostly involved the anteromedial facet of the coronoid process associated with lateral ulnar collateral ligament rupture and medial bone bruising. However, isolated radial head fractures were associated with medial collateral ligament rupture and lateral bone bruising. Combined coronoid and radial head fractures mostly involved a tip fracture of the coronoid with lateral ulnar collateral ligament rupture and lateral bone bruising. Thus surgeons may predict which ligament they should be aware of in the surgical field.

LEVEL OF EVIDENCE

Level III, prognostic study.

Simultaneous ipsilateral fractures of distal and proximal ends of the radius

We treated a patient with a rare combination of ipsilateral fractures of the distal and proximal ends of the radius. A man aged 42 years had simultaneous fractures of the distal and proximal ends of the radius (radial neck) following a roadside accident. The distal end fracture of the radius was treated with surgical reduction and T-plate volar fixation, and the undisplaced radial neck fracture was treated by an above elbow splintage for 2 weeks. The elbow mobilization was started at 2 weeks. The distal radius was protected for another 4 weeks in a below elbow functional brace. Ipsilateral proximal and distal radial fracture is an uncommon injury pattern. The series illustrates a number of problems associated with this combination. Firstly, one should be aware of this rare injury pattern and there should be greater emphasis on clinical examination of elbow in cases of wrist injuries and vice versa. Once diagnosed, one faces the dilemma of appropriate management in these cases. The appropriate management will depend on the injury characteristics including the age of the patient and the fracture pattern. One should try to preserve the radial head to prevent a possible proximal radial migration especially in younger patients.

Beveled posteromedial corner of the radial head: a three-dimensional micro-computed tomography modeling study

The posteromedial quadrant of the radial head is known to be different from the other quadrants. However, the explanation of this unique anatomical feature remains elusive. Hence, this study was designed to address this unique anatomical variance using three-dimensional μCT (micro-computed tomography) analysis. Nine fresh cadaveric radial heads were scanned using μCT. Three-dimensional subchondral bone and cartilage models were rendered. Both models were separated into the four quadrants at both the periphery (rim) and the articulating dish (fovea): anteromedial (AM), posteromedial (PM), posterolateral (PL), and anterolateral (AL). Each quadrant was analyzed in terms of (1) subchondral bone porosity (SBP), (2) mean subchondral bone thickness (MSBT), and (3) mean cartilage thickness (MCT). There was a significant difference between the fovea and the rim in terms of its microarchitectural features. Although within the fovea, the PM quadrant did not differ significantly from the other quadrants, a significant difference was found within the rim. In terms of SBP, PM, AM, PL and AL were calculated as 33, 37, 36 and 35%, respectively. In terms of MSBT, PM, AM, PL and AL were calculated as 0.11, 0.10, 0.09, and 0.09 mm, respectively. In terms of MCT, PM, AM, PL and AL were calculated 1.09, 0.81, 0.84 and 0.83 mm, respectively. The PM corner of the radial head between the 8 and 9 o'clock positions, was beveled. This might explain why the PM quadrant of the rim differed significantly from the other quadrants in terms of its microarchitectural features.

Complex elbow instability: surgical management of elbow fracture dislocations

There are three main patterns of complex elbow instability: posterolateral (terrible triad), varus posteromedial (anteromedial coronoid fracture with lateral collateral ligament complex disruption), and trans-olecranon fracture dislocations.Radial head fractures, in the setting of complex elbow instability, often require internal fixation or arthroplasty; the outcome of radial head replacement is dictated by adequate selection of the head diameter, correct restoration of radial length, and proper alignment and tracking.Small coronoid fractures can be ignored. Larger coronoid fractures, especially those involving the anteromedial facet, require fixation or graft reconstruction, particularly in the presence of incongruity.The lateral collateral ligament complex should be repaired whenever disrupted. Medial collateral ligament disruptions seem to heal reliably without surgical repair provided all other involved structures are addressed.The most common mistakes in the management of trans-olecranon fracture dislocations are suboptimal fixation, lack of fixation of coronoid fragments, and lack of restoration of the natural dorsal angulation of the ulna. Cite this article: Sanchez-Sotelo J, Morrey M. Complex elbow instability. EFORT Open Rev 2016;1:183-190.

Clinical and radiographic outcome of revision surgery of radial head prostheses: midterm results in 16 patients

BACKGROUND

Little is known about revision surgery of radial head arthroplasty. The aim of this study was to report on the clinical and radiographic outcome of revision arthroplasty of the elbow with a bipolar metallic radial head prosthesis.

METHODS

Between 2006 and 2013, we used either a press-fit or cemented RHS bipolar radial head prosthesis for revision surgery of radial head arthroplasty in 16 patients. Patients were prospectively enrolled in the study. Differences in outcome parameters before and after revision surgery were compared.

RESULTS

At a mean follow-up of 75 months (range, 36-116 months), none of the revised radial head prostheses needed a second revision. None of the stems showed radiographic signs of loosening. In 1 patient the head was dissociated from the prosthesis. The average flexion-extension arc was 127° (range, 105°-140°), and the average pronation-supination arc was 138° (range, 90°-160°). Stability scores improved after revision surgery, resulting in 13 stable elbows (P = .01). In 8 patients the Oxford Elbow Score was between 37 and 48 points. The percentage of patients with either good or excellent results according to the Mayo Elbow Performance Score was 63%. The mean score on the EQ-5D (EuroQol Five Dimensions) was 80 (range, 63-100), and the visual analog scale scores both for pain at rest and for pain with activity improved to 3 (range, 0-9) and 4 (range, 0-9), respectively (P < .001). All but 1 patient was satisfied with the results of the revision procedure.

CONCLUSION

The clinical and radiographic outcomes of revision surgery of a radial head prostheses are favorable.

[Not Available]

Zusammenfassung. Radiuskopffrakturen sind zwar sehr häufige Verletzungen, heilen meist aber relativ schnell und unkompliziert aus. Mit dieser Häufigkeit und «Einfachheit» geht jedoch eine gewisse Bagatellisierung einher. Aber selbst bei den einfachsten Radiuskopffrakturen liegt in bis zu 18 % der Fälle eine Begleitverletzung der Weichteile vor. Werden diese übersehen und/oder nicht behandelt, können sie schwere Folgeschäden verursachen. In Anbetracht dieser Problematik sollte der klinische Verlauf bei diesen Patienten genau verfolgt werden. Ein Ausbleiben der Schmerzlinderung nach zwei Wochen konservativer Therapie sollte eine weitere Abklärung nach sich ziehen.

Coronoid reconstruction with an osteochondral radial head graft

BACKGROUND

Chronic coronoid deficiency can occur subsequent to coronoid fracture malunion/nonunion or to coronoid hypoplasia or dysplasia resulting from injury during development. Several surgical options have been described to treat this difficult condition, but results are equivocal. We hypothesized that a modified coronoid reconstruction using a radial head osteochondral graft could restore elbow stability and congruity and that a technique involving rigid internal fixation would promote graft union.

METHODS

The coronoid was reconstructed using an osteochondral fragment from a frozen allograft radial head in 3 young women affected by complex post-traumatic elbow instability and incongruity resulting from coronoid deficiency. To promote bone healing, the fragment was kept as large as could be fitted in place, the cut surface compressed onto the remaining coronoid was as large as possible, the medial portion of the radial head (containing dense bone) was used, and 3 lag screws were inserted in different directions.

RESULTS

At a mean follow-up of 26 months, all 3 patients achieved a painless, congruent stable joint with a functional range of motion. Computed tomography scans performed 3 months after surgery showed complete union of the graft in all the patients. Each patient rated herself as "almost normal" or "greatly improved" on the Summary Outcome Determination scale.

CONCLUSION

Coronoid reconstruction with a radial head osteochondral allograft was successful in restoring stability and function in chronically unstable elbows with coronoid deficiency. Strong fixation using a large segment of the medial radial head achieved rapid graft healing.

Outcomes of Concomitant Fractures of the Radial Head and Capitellum: The "Kissing Lesion"

BACKGROUND

Radial head compression against the capitellum may cause concomitant fracture of the capitellum. The purpose of this study was to investigate if radial head fracture type is associated with a concomitant fracture of the capitellum.

PATIENTS AND METHODS

Data were identified from five area hospitals. We retrieved records of patients older than 18 years of age who underwent treatment for concomitant capitellum fracture and radial head fracture between January 2002 and January 2013. Patients with olecranon fractures or trochlea fractures were excluded.

RESULTS

A total of 10 patients with a radial head fracture and a concomitant capitellum fracture were included. Based on the operative reports, nine radial head fractures were classified as Hotchkiss modification of the Mason classification type II, and one was classified as type I. Based on the available radiographs and computed tomography, three capitellum fractures were type I, and seven were type II according to the Grantham classification.

CONCLUSION

Surgeons have to be alert to capitellar damage in case of a Hotchkiss type II radial head fracture.

LEVEL OF EVIDENCE

This is a level IV, therapeutic, retrospective study.

The yield of subsequent radiographs during nonoperative treatment of radial head and neck fractures

OBJECTIVES

After diagnosis of an isolated radial head or neck fracture and selection of nonoperative treatment, the value of subsequent radiographs is uncertain. This study tested the null hypothesis that there are no patient, surgeon, or injury factors associated with alteration in patient management based on subsequent radiographs. Secondarily, we tested the null hypothesis that the use of subsequent radiographs is not associated with patient, surgeon, and fracture characteristics.

METHODS

We identified 415 adult patients with nonoperative treatment for isolated Broberg and Morrey modified Mason type 1 or 2 fractures at a large urban hospital system during years 2013 and 2014. Patient demographics, fracture characteristics, provider characteristics, and treatment details were obtained from a hospital database. Bivariate analysis and multivariable logistic regression modeling were performed.

RESULTS

One of 255 patients with 262 fractures that had subsequent radiographs (0.4%) was offered surgery but declined. In multivariable analysis, displaced fractures were more likely to have subsequent radiographs, but surgeon-to-surgeon variation was a far more influential factor.

CONCLUSIONS

Radiographs subsequent to diagnosis do not alter treatment of radial head fractures with no associated ligament injuries or fractures. The substantial surgeon-to-surgeon variation in the use of subsequent radiographs suggests that this may be a good focus for quality improvement initiatives.

Acute unstable complex radial head and neck fractures fixed with a mini T-shaped plate in a 20-year-old man: a case report

Acute unstable complex radial head and neck fractures in adults are seldom reported in the literature. Early recognition and appropriate management are essential to prevent long-term consequences of the loss of elbow function, forearm rotation, and chronic pain. Here, we describe an unusual case of a 20-year-old man who exhibited acute unstable complex fractures of the head and neck of the right radius without other injuries or comorbidity. An open reduction and mini T-shaped plate fixation were performed within 3 hours after injury, and the results were satisfactory. A long plaster fixation was continued for 3 weeks. A gradual mobilization was started after the removal of the plaster under the supervision of a physiotherapist. At the 12-month follow-up, no complications associated with the use of the mini T-shaped plate were noted, and the Mayo Elbow Performance Score was 97 (excellent). To our knowledge, acute unstable complex radial head and neck fractures in adults can be successfully treated with a mini T-shaped plate reconstruction technique.