Elbow joint laxity after experimental radial head excision and lateral collateral ligament rupture: efficacy of prosthetic replacement and ligament repair

The objectives of this experimental study were to investigate the effect of radial head excision and lateral collateral ligament (LCL) division on elbow joint laxity and to determine the efficacy of radial head prosthetic replacement and LCL repair. Valgus, varus, internal rotation, and external rotation of the ulna were measured during passive flexion-extension and application of a 0.75-Nm torque in 6 intact cadaveric elbows and after (1) either excision of the radial head or division of the LCL, (2) removal of both constraints, (3) isolated radial head prosthetic replacement, (4) isolated LCL repair, and (5) radial head replacement combined with LCL repair. Isolated radial head excision increased varus (mean, 4.8 degrees) and external rotatory laxity (mean, 7.1 degrees), as did isolated LCL division (mean, 14.1 degrees for varus; mean, 14.7 degrees for external rotation). After removal of both constraints, varus and external rotatory laxities were increased by 19.0 degrees and 20.1 degrees, respectively, compared with the intact specimens. Isolated radial head replacement reduced mean varus laxity to 14.6 degrees and mean external rotatory laxity to 14.8 degrees. Isolated LCL repair normalized varus laxity but resulted in a 2.9 degrees increase in external rotatory laxity. The combined procedures restored laxity completely. The radial head is a constraint to varus and external rotation in the elbow joint, functioning by maintaining tension in the LCL. Still, removal of both constraints induces severe laxity, and in this case, prosthetic replacement may substitute for the constraining capacity of the native radial head. The combination of LCL repair and radial head replacement restores laxity completely, but an isolated LCL repair performs almost as well, probably by compensating for the ligamentous tension lost from radial head excision.     

Contribution of monoblock and bipolar radial head prostheses to valgus stability of the elbow.

BACKGROUND: The purpose of this study was to evaluate the stabilizing effect of radial head replacement in cadaver elbows with a deficient medial collateral ligament. METHODS: Passive elbow flexion with the forearm in neutral rotation and in 80 degrees of pronation and supination was performed under valgus and varus loads (1) in intact elbows, (2) after a surgical approach (lateral epicondylar osteotomy of the distal part of the humerus), (3) after release of the anterior bundle of the medial collateral ligament, (4) after release of the anterior bundle of the medial collateral ligament and resection of the radial head, and (5) after subsequent replacement of the radial head with each of three different types of radial head prostheses (a Wright monoblock titanium implant, a KPS bipolar Vitallium [cobalt-chromium]-polyethylene implant, and a Judet bipolar Vitallium-polyethylene-Vitallium implant) in the same cadaver elbow. Total valgus elbow laxity was quantified with use of an electromagnetic tracking device. RESULTS: The mean valgus laxity changed significantly (p < 0.001) as a factor of constraint alteration. The greatest laxity was observed after release of the medial collateral ligament together with resection of the radial head (11.1 degrees +/- 5.6 degrees). Less laxity was seen following release of the medial collateral ligament alone (6.8 degrees +/- 3.4 degrees), and the least laxity was seen in the intact state (3.4 degrees +/- 1.6 degrees). Forearm rotation had a significant effect (p = 0.003) on valgus laxity throughout the range of flexion. The laxity was always greater in pronation than it was in neutral rotation or in supination. The mean valgus laxity values for the elbows with a deficient medial collateral ligament and an implant were significantly greater than those for the medial collateral ligament-deficient elbows before radial head resection (p < 0.05). The implants all performed similarly except in neutral forearm rotation, in which the elbow laxity associated with the Judet implant was significantly greater than that associated with the other two implants. CONCLUSIONS AND CLINICAL RELEVANCE: This study showed that a bipolar radial head prosthesis can be as effective as a solid monoblock prosthesis in restoring valgus stability in a medial collateral ligament-deficient elbow. However, none of the prostheses functioned as well as the native radial head, suggesting that open reduction and internal fixation to restore radial head anatomy is preferable to replacement when possible.     

Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow

BACKGROUND: The purpose of this study was to evaluate the role of the radial head and the coronoid process as posterolateral rotatory stabilizers of the elbow and to determine the stabilizing effect of radial head replacement and coronoid reconstruction. METHODS: The posterolateral rotatory displacement of the ulna was measured after application of a valgus and supinating torque (1). in seven intact elbows, (2). after radial head excision, (3). after sequential resection of the coronoid process, (4). after subsequent insertion of each of two different types of metal radial head prostheses (a rigid implant and a bipolar implant with a floating cup), and (5). after subsequent reconstruction of the coronoid with each of two different techniques in the same cadaveric elbow. RESULTS: The posterolateral rotatory laxity averaged 5.4 degrees in the intact elbows. The surgical approach used in this study insignificantly increased the mean laxity to 9 degrees. Excision of the radial head in an elbow with intact collateral ligaments caused a mean posterolateral rotatory laxity of 18.6 degrees (p < 0.0001). Additional removal of 30% of the height of the coronoid fully destabilized the elbows, always resulting in ulnohumeral dislocation despite intact ligaments. Implantation of a rigid radial head prosthesis stabilized the elbows. However, a mean laxity of 16.9 degrees persisted after insertion of a floating prosthesis (p < 0.0001). The elbows with a defect of 50% or 70% of the coronoid, loss of the radial head, and intact ligaments could not be stabilized by radial head replacement alone, but additional coronoid reconstruction restored stability. CONCLUSIONS: The results of this study suggest that the coronoid and the radial head contribute significantly to posterolateral rotatory stability.     

Metallic radial head arthroplasty improves valgus stability of the elbow

The stabilizing influence of radial head arthroplasty was studied in eight medial collateral ligament deficient anatomic specimen elbows. An elbow testing apparatus, which used computer controlled pneumatic actuators to apply tendon loading, was used to simulate active elbow flexion. The motion pathways of the elbow were measured using an electromagnetic tracking device, with the forearm in supination and pronation. As a measure of stability, the maximum varus to valgus laxity over the range of elbow flexion was determined from the difference between varus and valgus gravity loaded motion pathways. After transection of the medial collateral ligament, the radial head was excised and replaced with either a silicone or one of three metallic radial head prostheses. Medial collateral ligament transection caused a significant increase in the maximum varus to valgus laxity to 18.0 degrees +/- 3.2 degrees. After radial head excision, this laxity increased to 35.6 degrees +/- 10.3 degrees. The silicone implant conferred no increase in elbow stability, with a maximum varus to valgus laxity of 32.5 degrees +/- 15.5 degrees. All three metallic implants improved the valgus stability of the medial collateral ligament deficient elbow, providing stability similar to the intact radial head. The use of silicone arthroplasty to replace the radial head in the medial collateral ligament deficient elbow must be questioned. Metallic radial head arthroplasty provides improved valgus stability, approaching that of an intact radial head.     

重建肘关节外翻稳定性的生物力学研究

目的　评价肘关节桡骨头 (radial head,RH)切除、尺侧副韧带 (medial collateral ligament,MCL )损伤以及 RH假体置换、MCL重建后的外翻稳定性。　方法　新鲜成人尸体上肢标本 12侧 ,制成肘关节“骨 -韧带”标本 ,在2 N· m的外翻力矩作用下 ,分别在肘关节 0°、30°、6 0°、90°和 12 0°伸屈时 ,测量肘关节外翻松弛度 :1完整肘关节(n=12 ) ;2 MCL切断 (n=6 ) ;3RH切除 (n=6 ) ;4 MCL切断 +RH切除 (n=12 ) ;5 RH假体置换 (n=6 ) ;6 MCL重建(n=6 ) ;7RH假体置换 +MCL重建 (n=12 )。用 SPSS 10 .0统计软件包作方差分析 ,比较各组的外翻稳定性。　结果　完整肘关节的平均外翻松弛度最小 ;RH切除后 ,外翻松弛度增大 ;单纯 MCL切断 ,外翻松弛度大于单纯 RH切除 (P<0 .0 1) ;MCL切断 +RH切除 ,外翻稳定性最差 ;行 RH假体置换 ,对稳定性有改善 ;MCL重建与完整 MCL差异无统计学意义 (P>0 .0 5 ) ;RH假体置换同时重建 MCL ,效果最好。　结论　 MCL是抵抗肘关节外翻应力最主要的因素 ,RH是次要因素。在重建肘关节的外翻稳定性方面 ,MCL的重建比 RH的假体置换更重要。在无条件行 RH假体置换时 ,修复MCL是较好的手术方式。     

Importance of a radial head component in Sorbie unlinked total elbow arthroplasty

The effects of a radial head component on total elbow arthroplasty kinematics and stability were evaluated using an anatomic design unlinked total elbow prosthesis. An electromagnetic tracking device recorded motion and varus and valgus displacements under various conditions in 10 cadaveric elbows. The motion patterns of the intact elbows and the Sorbie-Questor total elbow prostheses with a radial head component were similar, as both tended to have a valgus position in extension, varus at midflexion, and more valgus toward full flexion. Under conditions of simulated muscle loading, the maximum valgus and varus laxity of the elbow prosthesis was, on average, 8.6 degrees +/- 4.0 degrees greater than normal. Without the radial head component, however, significant kinematic disturbances and instabilities were seen. The varus and valgus displacements were 13.3 degrees +/- 5.5 degrees greater than the intact elbows. One total elbow arthroplasty without a radial head dislocated during testing. Increasing the muscle loading across the elbow significantly enhanced dynamic stability of the total elbow arthroplasties, especially in the extension half of elbow motion where instability is greatest. However, this dynamic enhancement of stability was seen only in those elbows in which the radial head component had been implanted. The radial head component is an important stabilizer, particularly in extension for this prosthesis, and possibly for other unlinked total elbow prostheses. Although instability of unlinked prostheses depends on the prosthetic design, the use of a radial head replacement may be an important factor in preventing such instability. Perhaps even more importantly, a radial head component balances the load distribution across the articulation, which could decrease stress on the ulnohumeral articulation and therefore possibly reduce polyethylene wear, osteolysis, and loosening.     

Radial head fracture in the medial collateral ligament deficient elbow; biomechanical comparison of fixation, replacement and excision in human cadavers

A widely used clinical recommendation is that in the presence of medial collateral ligament injuries, two-part radial head fractures should be fixed rather than excising or replacing the radial head. Direct biomechanical data comparing fracture fixation, radial head replacement and excision in a human cadaveric elbow model, have not been previously described. Such comparison is clinically important as with the increasing availability of radial head implants and promising follow up results, the role of radial head replacement in fracture management may have to be redefined. In this study, five fresh cadaveric elbows had radial head fracture creation and medial collateral ligament division, fracture fixation, radial head replacement and excision. Valgus and varus laxity were determined using an electromagnetic tracking system. Radial head replacement leads to a similar valgus (P=0.80) [corrected] laxity as compared to radial head fixation. Radial head excision resulted in a significantly greater valgus laxity as compared to radial head fixation (P=0.02) or replacement (P=0.03). Both radial head excision and replacement led to a greater varus laxity as compared to fixation. Our results suggest that in the elbow with medial collateral ligament injury and two-part radial head fracture, fixation is overall biomechanically superior as compared to replacement and excision.     

The effect of radial head fracture size on elbow kinematics and stability.

This study determined the effect of radial head fracture size and ligament injury on elbow kinematics. Eight cadaveric upper extremities were studied in an in vitro elbow simulator. Testing was performed with ligaments intact, with the medial collateral (MCL) or lateral collateral (LCL) ligament detached, and with both the MCL and LCL detached. Thirty degree wedges were sequentially removed from the anterolateral radial head up to 120 degrees . Valgus angulation and external rotation of the ulna relative to the humerus were determined for passive motion, active motion, and pivot shift testing with the arm in a vertical (dependent) orientation. Maximum varus-valgus laxity was calculated from measurements of varus and valgus angulation with the arm in horizontal gravity-loaded positions. No effect of increasing radial head fracture size was observed on valgus angulation during passive and active motion in the dependent position. In supination, external rotation increased with increasing fracture size during passive motion with LCL deficiency and both MCL and LCL deficiency. With intact ligaments, maximum varus-valgus laxity increased with increasing radial head fracture size. With ligament disruption, elbows were grossly unstable, and no effect of increasing radial head fracture size occurred. During pivot shift testing, performed with the ligaments intact, subtle instability was noted after resection of one-third of the radial head. In this in vitro biomechanical study, small subtle effects of radial head fracture size on elbow kinematics and stability were seen in both the ligament intact and ligament deficient elbows. These data suggest that fixation of displaced radial head fractures less than or equal to one-third of the articular diameter may have some biomechanical advantages; however, clinical correlation is required.     

The effect of radial head excision and arthroplasty on elbow kinematics and stability

BACKGROUND: Radial head fractures are common injuries. Comminuted radial head fractures often are treated with radial head excision with or without radial head arthroplasty. The purpose of the present study was to determine the effect of radial head excision and arthroplasty on the kinematics and stability of elbows with intact and disrupted ligaments. We hypothesized that elbow kinematics and stability would be (1) altered after radial head excision in elbows with intact and disrupted ligaments, (2) restored after radial head arthroplasty in elbows with intact ligaments, and (3) partially restored after radial head arthroplasty in elbows with disrupted ligaments. METHODS: Eight cadaveric upper extremities were studied in an in vitro elbow simulator that employed computer-controlled actuators to govern tendon-loading. Testing was performed in stable, medial collateral ligament-deficient, and lateral collateral ligament-deficient elbows with the radial head intact, with the radial head excised, and after radial head arthroplasty. Valgus angulation and rotational kinematics were determined during passive and simulated active motion with the arm dependent. Maximum varus-valgus laxity was measured with the arm in a gravity-loaded position. RESULTS: In specimens with intact ligaments, elbow kinematics were altered and varus-valgus laxity was increased after radial head excision and both were corrected after radial head arthroplasty. In specimens with disrupted ligaments, elbow kinematics were altered after radial head excision and were similar to those observed in specimens with a native radial head after radial head arthroplasty. Varus-valgus laxity was increased after ligament disruption and was further increased after radial head excision. Varus-valgus laxity was corrected after radial head arthroplasty and ligament repair; however, it was not corrected after radial head arthroplasty without ligament repair. CONCLUSIONS: Radial head excision causes altered elbow kinematics and increased laxity. The kinematics and laxity of stable elbows after radial head arthroplasty are similar to those of elbows with a native radial head. However, radial head arthroplasty alone may be insufficient for the treatment of complex fractures that are associated with damage to the collateral ligaments as arthroplasty alone does not restore stability to elbows with ligament injuries.     

The stability of the elbow following excision of the radial head and transection of the annular ligament. An experimental study

The stabilizing role of the lateral ligament complex and the radial head were investigated in ten osteoligamentous elbow preparations. The annular ligament was the prime stabilizer of the lateral aspect of the elbow. Transection of the annular ligament caused maximal varus and external rotatory instability of 13.7 degrees and 32.8 degrees respectively, with an elbow flexion about 70 degrees. Isolated excision of the radial head caused slight varus and external rotatory instability of 4.8 degrees and 10.4 degrees respectively, with an elbow flexion about 40 degrees. The lateral collateral ligament had only a minor stabilizing function of the elbow. The stability of the elbow after excision of the radial head may be improved by proper preservation of the annular ligament.     

The Wrightington approach to the radial head: biomechanical comparison with the posterolateral approach

PURPOSE: The Wrightington approach to the radial head involves elevating anconeus from the proximal ulna to expose the supinator crest and then osteotomizing the bony insertion of the lateral ligament complex to the ulna. This avoids incising through the substance of the lateral ligament complex. The purpose of this study was to determine if there is any difference in laxity changes between using the posterolateral versus the Wrightington approach in performing surgery upon the radial head in a cadaveric model. METHODS: Ten cadaveric elbows had a radial head fracture created and the medial collateral ligament divided. They then sequentially had the posterolateral or Wrightington approach to the radial head, fracture fixation, head excision, and replacement. After each step, valgus and varus laxity and ulnar rotation were determined with an electromagnetic tracking system. RESULTS: After each step, there was a greater increase in valgus and varus laxity in the posterolateral group compared with the Wrightington group. After surgical exposure, radial head fracture fixation, and radial head excision, there was a statistically significant difference in the changes in rotation between the posterolateral and Wrightington approaches, with the former resulting in an increase in external and the latter an increase in internal rotation. CONCLUSIONS: These results suggest that the newly described Wrightington approach is biomechanically superior to the posterolateral approach with regard to changes in elbow laxity after surgery to the radial head.     

The effect of suture fixation of type I coronoid fractures on the kinematics and stability of the elbow with and without medial collateral ligament repair

The objective of this study was to determine the effect of suture repair of type 1 coronoid fractures on elbow kinematics in ligamentously intact and medial collateral ligament (MCL)-deficient elbows. Cadaveric testing was performed in stable and MCL-deficient elbows with radial head arthroplasty and with the coronoid intact, with the coronoid fractured, and after suture repair. Ulna versus humerus angulation was measured during active motion. Varus and valgus motion pathways were measured during passive gravity-loaded flexion. With intact ligaments, there was a small increase in valgus angulation after a type 1 fracture that was not corrected with suture fixation. With MCL deficiency, there was no change in kinematics regardless of coronoid status. Type 1 coronoid fractures cause only small changes in elbow kinematics that are not corrected with suture repair. MCL repair, rather than type 1 coronoid fixation, should be considered if the elbow remains unstable after radial head repair or replacement and lateral ligament repair.     

Valgus stability of the elbow. A definition of primary and secondary constraints

The stabilizing structures of the elbow that resist valgus stress were studied with a tracking device in a model simulating active motion and muscle activity. By varying the order of serial release of the medial collateral ligament complex and removal of the radial head, each structure's contribution to valgus stability against the effect of gravity was determined. In the otherwise intact elbow, absence of the radial head does not significantly alter the three-dimensional characteristics of motion in the elbow joint. Isolated medial collateral release, on the other hand, causes increases in abduction rotation of about 6 degrees-8 degrees in magnitude. Releasing both structures results in gross abduction laxity and elbow subluxation. This study defines the medial collateral ligament (MCL) as the primary constraint of the elbow joint to valgus stress and the radial head as a secondary constraint. This definition facilitates the proper management of patients with radial head fractures and MCL disruption. The comminuted radial head fracture uncomplicated by MCL insufficiency should be treated by excision without the need for an implant and without concern of altering the normal kinematics of the elbow.     

Kinematics of partial and total ruptures of the medial collateral ligament of the elbow

In this study the kinematics of partial and total ruptures of the medial collateral ligament of the elbow are investigated. After selective transection of the medial collateral ligament of 8 osteoligamentous intact elbow preparations was performed, 3-dimensional measurements of angular displacement, increase in medial joint opening, and translation of the radial head were examined during application of relevant stress. Increase in joint opening was significant only after complete transection of the anterior part of the medial collateral ligament was performed. The joint opening was detected during valgus and internal rotatory stress only. After partial transection of the anterior bundle of the medial collateral ligament was performed, there was an elbow laxity to valgus and internal rotatory force, which became significant after transection of 100% of the anterior bundle of the medial collateral ligament and was maximum between 70 degrees to 90 degrees of flexion. No radial head movement was seen after partial or total transection of the anterior bundle of the medial collateral ligament was performed. In conclusion, this study indicates that valgus or internal rotatory elbow instability should be evaluated at 70 degrees to 90 degrees of flexion. Detection of partial ruptures in the anterior bundle of the medial collateral ligament based on medial joint opening and increased valgus movement is impossible.     

The stability of the elbow following excision of the radial head and transection of the annular ligament

Summary The stabilizing role of the lateral ligament complex and the radial head were investigated in ten osteoligamentous elbow preparations. The annular ligament was the prime stabilizer of the lateral aspect of the elbow. Transection of the annular ligament caused maximal varus and external rotatory instability of 13.7° and 32.8° respectively, with an elbow flexion about 70°. Isolated excision of the radial head caused slight varus and external rotatory instability of 4.8° and 10.4° respectively, with an elbow flexion about 40°. The lateral collateral ligament had only a minor stabilizing function of the elbow. The stability of the elbow after excision of the radial head may be improved by proper preservation of the annular ligament.     

Fractures of the radial head and neck treated with radial head excision

BACKGROUND: The reported long-term outcomes of the treatment of radial head and neck fractures with excision of the radial head have been mixed. The purpose of the present study was to evaluate the long-term outcomes of primary or delayed radial head excision for the treatment of these fractures. METHODS: Sixty-one individuals (mean age, forty-four years) with thirty-nine Mason type-II, ten Mason type-III, and twelve Mason type-IV fractures were evaluated subjectively, objectively, and radiographically at a mean of eighteen years (range, eleven to thirty-three years) after treatment. Forty-three fractures were treated with primary radial head excision, and the remaining eighteen were treated with delayed radial head excision at a median of five months (range, one to 238 months) after the injury. RESULTS: At the time of follow-up, twenty-eight individuals had no symptoms, twenty-seven had occasional elbow pain, and six had daily pain. Four individuals with daily pain had had a Mason type-IV fracture. The range of motion of the formerly injured upper extremities was slightly less than that of the uninjured upper extremities in terms of flexion (139 degrees +/- 11 degrees compared with 142 degrees +/- 8 degrees ), extension (-7 degrees +/- 12 degrees compared with -1 degrees +/- 6 degrees ), and supination (77 degrees +/- 20 degrees compared with 85 degrees +/- 10 degrees ) (all p < 0.01). A higher percentage of formerly injured elbows than uninjured elbows had cysts, sclerosis, and osteophytes (73% compared with 7%; p < 0.001), but none had a reduced joint space. No differences were found between the outcomes for individuals treated with a primary radial head excision and those for individuals treated with a delayed excision. CONCLUSIONS: Following a displaced radial head or neck fracture, excision of the radial head often leads to a good or fair result. We found no differences in outcome between primary and delayed radial head excisions following a Mason type-II, III, or IV fracture. The outcomes are associated with the type of fracture, with Mason type-IV fractures having the worst results, rather than with the timing of the radial head excision (primary or delayed).     

Valgus stability of the elbow

The valgus stabilizers of the elbow have been identified anatomically, but their relative importance has not been quantified. The purpose of this study was to analyze the acute changes of the torque-displacement curve to valgus stress following (a) section of the posterior portion of the medial collateral ligament; (b) excision of the radial head; (c) prosthetic replacement of the radial head; and (d) excision of the anterior portion of the medical collateral ligament. Thirty cadaver specimens underwent load-displacement testing in three positions: 0 degrees, 45 degrees, and 90 degrees of flexion. The anterior portion of the medial collateral ligament was the primary stabilizer of the elbow to valgus stress. The relative contribution of the posterior ligament was minimal. After excision of the radial head alone, the slope of the load-displacement curve decreased an average of 30%. Silicone rubber radial head replacement did not significantly improve the stability to valgus stress after radial head excision.     

Elbow joint stability following experimental osteoligamentous injury and reconstruction

Elbow joint dislocation was simulated in cadaveric specimens to quantify laxity induced by radial head and coronoid process lesions, either alone or in combination with collateral ligament insufficiency. The effects of lateral ligament reconstruction and radial head prosthesis replacement were also considered. Absence of the radial head and the coronoid process induced rotatory laxity of 145% and 128% (both P <.01), respectively, compared with the intact joint. When both were absent, the joints subluxated regardless of collateral ligament status. Isolated radial head prosthesis implantation prevented this subluxation, and laxity almost normalized. Lateral collateral ligament reconstruction prevented major laxity even in the absence of the radial head. Lateral collateral ligament reconstruction and radial head prosthetic replacement yielded restraint against gross instability in the maximal unstable situation (terrible triad). The lateral collateral ligament is the prime stabilizer to external rotation, and reconstruction of this alone, even with an absent radial head, is beneficial.     

Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures

BACKGROUND: The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and stiffness from prolonged immobilization. We managed these injuries with a standard surgical protocol, postulating that early intervention, stable fixation, and repair would provide sufficient stability to allow motion at seven to ten days postoperatively and enhance functional outcome. METHODS: We retrospectively reviewed the results of this treatment performed, at two university-affiliated teaching hospitals, in thirty-six consecutive patients (thirty-six elbows) with an elbow dislocation and an associated fracture of both the radial head and the coronoid process. Our surgical protocol included fixation or replacement of the radial head, fixation of the coronoid fracture if possible, repair of associated capsular and lateral ligamentous injuries, and in selected cases repair of the medial collateral ligament and/or adjuvant hinged external fixation. Patients were evaluated both radiographically and with a clinical examination at the time of the latest follow-up. RESULTS: At a mean of thirty-four months postoperatively, the flexion-extension arc of the elbow averaged 112 degrees +/- 11 degrees and forearm rotation averaged 136 degrees +/- 16 degrees. The mean Mayo Elbow Performance Score was 88 points (range, 45 to 100 points), which corresponded to fifteen excellent results, thirteen good results, seven fair results, and one poor result. Concentric stability was restored to thirty-four elbows. Eight patients had complications requiring a reoperation: two had a synostosis; one, recurrent instability; four, hardware removal and elbow release; and one, a wound infection. CONCLUSIONS: Use of our surgical protocol for elbow dislocations with associated radial head and coronoid fractures restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. We recommend early operative repair with a standard protocol for these injuries.