Comminuted radial head fractures treated with a modular metallic radial head arthroplasty. Study of outcomes

BACKGROUND: Comminuted fractures of the radial head are challenging to treat with open reduction and internal fixation. Radial head arthroplasty is an alternative treatment with results that compare favorably with those reported after open reduction and internal fixation of similar fractures. The purpose of this study was to evaluate the two-year outcomes and the rate of recovery of a closely followed cohort of patients in whom an unreconstructible radial head fracture had been treated with a modular metallic prosthesis. METHODS: Twenty-six patients (seventeen female and nine male; mean age, fifty-four years) with an unreconstructible comminuted radial head fracture and associated elbow injuries were treated with a modular metallic radial head arthroplasty. Patients who had presented more than four weeks following the injury or had had the radial head arthroplasty as a second-stage or salvage procedure were excluded. Of the twenty-six patients, twenty-two had an associated elbow dislocation, and thirteen of them also had an associated fracture of the coronoid process. Patients were prospectively followed at three, six, twelve, and twenty-four months. Self-reported limb function, general health, range of motion, and isometric strength were assessed by an independent observer. RESULTS: Following treatment of the injury, significant decreases in self-reported and measured impairments were noted over time, with the majority of the recovery occurring by six months and little further recovery noted between six and twenty-four months. There were slight-to-moderate deficits in the range of motion and strength compared with the values on the contralateral, unaffected side. Patient satisfaction was high at three months and remained high at two years. All elbow joints remained stable, no implant required revision, and there was no evidence of overstuffing of the joint. Mild osteoarthritis was seen in five (19%) of the twenty-six patients. CONCLUSIONS: An arthroplasty with a modular metallic radial head is a safe and effective option for the treatment of unreconstructible radial head fractures associated with other elbow injuries. Recovery primarily occurs by six months, with minimal additional improvements over the next eighteen months.     

Frakturendoprothetik der distalen Humerusfraktur

The treatment of choice for fractures of the distal humerus is double plate osteosynthesis. Due to anatomical preshaped angle stable plates the primary stability and management of soft tissues has been improved. However, osteoporotic comminuted fractures in the elderly are often not amenable to stable osteosynthesis and total elbow arthroplasty has been established as an alternative therapy. Although complication rates have been reduced, complications of total elbow arthroplasty are still much more frequent than in total hip replacement. Furthermore, patients are advised not to exceed a weight bearing of 5 kg. Therefore, the indications for elbow arthroplasty must be evaluated very strictly and should be reserved for comminuted distal humeral fractures in the elderly with poor bone quality that are not amenable to stable osteosynthesis or for simple fractures in cases of preexisting symptomatic osteoarthritis. This article introduces and discusses modern concepts of elbow arthroplasty, such as modular convertible prosthesis systems, hemiarthroplasty and radial head replacement in total elbow arthroplasty.     

Therapie der Radiusköpfchenfraktur

The treatment of radial head fractures is challenging for the trauma surgeon due to the complex functional anatomy of the elbow. Satisfactory results can only be achieved if the function and stability of the humeroradial joint are entirely restored. Thus, depending on the fracture type, ranging from non-displaced Mason type I fractures to comminuted Mason type III fractures, an individual treatment concept has to be established. Treatment protocols range from conservative treatment with short-term cast immobilization to open reduction and internal fixation according to AO-principles or to the implantation of a radial head prosthesis. In case of severe comminution of the radial head, resection arthroplasty might be indicated.     

Therapy for radial head fractures

The treatment of radial head fractures is challenging for the trauma surgeon due to the complex functional anatomy of the elbow. Satisfactory results can only be achieved if the function and stability of the humeroradial joint are entirely restored. Thus, depending on the fracture type, ranging from non-displaced Mason type I fractures to comminuted Mason type III fractures, an individual treatment concept has to be established. Treatment protocols range from conservative treatment with short-term cast immobilization to open reduction and internal fixation according to AO-principles or to the implantation of a radial head prosthesis. In case of severe comminution of the radial head, resection arthroplasty might be indicated.     

Indikation und Ergebnisse nach Radiuskopfprothesen

Treatment of unreconstructible comminuted fractures of the radial head (Mason type III or IV) remains controversial. Radial head excision was advocated for the management of these severe fractures in the past. Complications such as valgus elbow instability, elbow stiffness, and proximal radial migration can be the result. There is limited information on the outcome of arthroplasty with a radial head implant. The functional outcomes of 19 patients with arthroplasty of the radial head were evaluated after an average of 40.4 months. According to the functional rating index (Broberg and Morrey), 2 results were graded as poor, 6 as fair, and 11 as good or excellent. The poor and fair outcomes were associated with concomitant injuries. Elbow flexion of the injured extremity averaged 121±15°, extension ?19±12°, pronation 76±17°, and supination 73±18°. Valgus stability was restored and proximal radial migration did not occur. Complications included two luxations, but no wound infection. Patients treated with radial head prosthesis for a severely comminuted radial head fracture have mild to moderate impairment of the elbow and wrist. Arthroplasty with a radial head prosthesis was found to have been a safe and effective treatment option.     

Änderungen der stationären Versorgung

Fractures of the radial head are typically due to axial force. The treatment algorithm takes additional ligament injuries into account and demands an individual approach between reconstruction, resection and arthroplasty of the radial head. In case of a stable ulnar collateral ligament, radial head resection is the therapy of choice. Remaining valgus instability is an indication for radial head arthroplasty to restore axial and valgus stability and thus prevent proximal radial migration. Radial head arthroplasty is contraindicated in cases where radial head-preserving therapy might be possible. Therefore, in young patients an attempt of reconstruction is indicated even in comminuted fractures. Existing local or systemic inflammation excludes arthroplasty. Typical complications of radial head arthroplasty include cartilage loss at the capitulum, limited range of motion in the elbow joint and heterotopic ossifications. Furthermore, bone lysis at the shaft has to be expected.     

Newly defined fracture pattern specific to Mason III radial head fractures: fracture description, management and outcomes using screw fixation

Background: Radial head fractures are the most common type of elbow fracture and are universally classified under the Mason classification system. Mason type III fractures are comminuted and are the most difficult to treat, generally requiring plating if possible, or more commonly arthroplasty or excision, which gives a variable outcome. We hypothesized that a new and specific fracture pattern of the radial head (Mason III) can be treated successfully with screw fixation. Methods: Six patients presented to the senior surgeon's clinic with this unusual Mason III fracture pattern. In these patients, the fracture was acute, requiring an open reduction and internal fixation with the use of three headless compression screws. Average follow‐up time was 21 months. Using serial X‐rays and the Broberg–Morrey elbow score, the six acute fractures were evaluated radiologically and functionally. Results: All six patients had good to excellent results using the Broberg–Morrey scoring system. All patients showed radiological and clinical union within 3 months of injury. No patient required revision surgery or excision at a later date. Discussion: We have recognized a specific type of comminuted and displaced Mason III radial head fracture that has not previously been described in the literature. This type of fracture is amenable to open reduction internal fixation with buried compression screws giving a good to excellent outcome, while avoiding the common consequences seen with a radial head excision, arthroplasty or plate fixation.     

Is a Silastic Radial Head Still a Reasonable Option?

Background  

The importance of the radial head to elbow function and stability is increasingly apparent. Although preservation of the native radial head is preferred, severely comminuted fractures may necessitate resection or arthroplasty. Silastic radial head arthroplasty has been condemned on the basis of several sporadic reports of silicone synovitis. However, problems of “overstuffing,” cartilage wear, and motion loss are becoming apparent with metal prostheses, indicating this also is not an ideal solution. Thus, the choices remain controversial.     

桡骨头置换术治疗桡骨头严重粉碎性骨折

目的探讨桡骨头置换术治疗桡骨头严重粉碎性骨折的疗效。方法 2006年6月至2009年2月行桡骨头置换术治疗6例桡骨头严重粉碎性骨折患者,男4例,女2例;年龄24～36岁,平均27.6岁;均为MasonⅢ型、Ⅳ型。结果术后6例患者全部获得随访,随访时间为4～36个月,平均27个月。除1例患者活动时外侧有摩擦感、轻度疼痛外,其余患者均恢复良好。按Broberg-Morrey评分标准进行综合评定,优4例,良1例,可1例,差0例,平均93.8分,患者满意度为100%。结论人工桡骨头置换术能够恢复肘关节的稳定性及活动度,是治疗桡骨头粉碎性骨折的一种良好术式。     

Radial Head Fractures: Indications and Technique for Primary Arthroplasty

Abstract The treatment of complex radial head fractures remains a challenge for the orthopedic surgeon. Novel implants and improved surgical techniques have made reconstruction of the radial head with open reduction and internal fixation possible in most cases. However, extremely comminuted radial head fractures with associated instabilities still require replacement of the radial head with a prosthesis to allow rehabilitation with early motion of the elbow, and thereby optimizing the functional results of these potentially devastating injuries. In this article we discuss the surgical considerations related to radial head replacement, encompassing the indications for radial head arthroplasty, implant selection, surgical technique, rehabilitation protocols, and complications related to radial head prosthesis.     

Radial head arthroplasty with an uncemented modular metallic radial head prosthesis: short- and mid-term results

Background  

In comminuted radial head fractures, arthroplasty is an alternative treatment to open reduction and internal fixation or radial head excision. The purpose of this study was to evaluate the short- and mid-term results after the implantation of the EVOLVE™ uncemented modular metallic radial head prosthesis.     

Radial head,radiocapitellar and total elbow arthroplasties: A review of recent literature

The outcome of prosthetic elbow surgery is continually evolving. We thoroughly reviewed the literature on this issue to analyse the indications, outcomes and complications of the numerous types of implants currently in use. Radial head replacement is recommended in comminuted fractures of the radial head and in post-traumatic conditions. Medium- and long-term results prove to be satisfactory in the majority of cases, with no evidence to indicate that some prostheses (monopolar vs. bipolar; cemented vs. press-fit) are more effective than others; nonetheless, the bipolar-cemented implant was found to be associated with a lower revision rate than other prostheses. Unicompartmental arthroplasty has recently been used for the treatment of osteoarthritis and rheumatoid arthritis when the lateral compartment is prevalently involved; the results reported to date have been encouraging, although further studies are warranted to confirm the validity of these implants. Total elbow arthroplasty is performed in a range of conditions, including distal humerus fractures in the elderly and elbow arthritis. In the former condition, linked elbow replacement yields excellent results with few complications and a low revision rate. In elbow arthritis, total elbow arthroplasty is indicated when patients suffer from disabling pain, stiffness and/or instability that prevent them from performing daily activities. Unlinked elbow arthroplasty, which is used above all in rheumatoid arthritis, also yields satisfactory results, although the risk of instability persists. The use of linked elbow arthroplasty, which yields similar results but lower revision rates, has consequently increased. Lastly, the results yielded by linked elbow prosthesis in post-traumatic conditions are good, although not quite as good as those obtained in rheumatoid arthritis. Early mechanical failure may occur in younger and more active patients after elbow arthroplasty. However, the careful selection of patients who are prepared to accept functional limitations imposed by elbow implants will enable indications for elbow arthroplasty to be extended to young subjects, particularly when no other therapeutic options are available.     

切开复位on-table技术重建并内固定治疗桡骨头粉碎骨折

目的探讨on-table技术复位重建内并固定治疗桡骨头粉碎性骨折的临床疗效。方法采用切开复位on-table技术重建并克氏针、螺钉钢板、内固定术治疗16例桡骨头粉碎骨折患者,评价肘关节功能。结果患者均获随访,时间12~18个月。骨折愈合,时间6~12个月。末次随访时肘关节活动范围:伸直0°~23°,屈曲86°~139°,旋前56°~72°,旋后36°~83°。按照Broberg-Morrey功能评价:优11例,良2例,可3例。结论切开复位on-table技术重建内固定治疗桡骨头粉碎性骨折能取得较好的效果,是桡骨头切除或桡骨头置换之外的又一选择。     

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.     

Comminuted fractures of the radial head treated by the Judet floating radial head prosthesis

Excision is not a suitable treatment for all comminuted fractures of the radial head. In elbows where instability can be predicted, a replacement arthroplasty of the radial head is more effective. The aim of this paper was to present the medium-term results of the Judet floating radial head prosthesis. This operation was performed on 14 patients between 1992 and 2003, of whom 12 were reviewed at a mean follow-up of five years and three months (1 to 12 years). The outcome was assessed using the Mayo elbow performance score and a modified Disability of Arm Shoulder Hand (DASH) questionnaire. There were six excellent results, four good, one fair and one poor, as graded by the Mayo score. The mean DASH score was 23.9/100 (0 to 65.8/100). The only significant complication occurred in one patient who developed a severe complex regional pain syndrome. There were no patients with secondary instability of the elbow, implant loosening, cubitus valgus, osteoporosis of the capitellum, or pain in the forearm and wrist. Our experience, combined with that of other authors using this device, has encouraged us to continue using the Judet prosthesis in comminuted fractures of the elbow where instability is a potential problem.     

冠突骨折及合并桡骨小头粉碎骨折生物力学

[目的]分析尺骨冠突骨折及合并桡骨小头粉碎骨折时肘关节的稳定性。[方法]选取上肢尸体标本8对，测试各种冠突骨折及合并桡骨小头粉碎骨折时肘外翻位移及外旋角。[结果]肘关节稳定性在冠突无骨折、Ⅰ型骨折、Ⅱ型骨折各组间无显著差异，冠突Ⅲ型骨折时显著不稳定。[结论]冠突骨折及合并桡骨小头粉碎骨折在冠突Ⅰ型、Ⅱ型骨折时肘关节稳定，可行桡骨小头切除术，Ⅲ型骨折不稳定，应修复桡骨小头或假体置换，并修复桡侧副韧带。     

Fractures of the elbow's lateral column radial head and capitellum

Fractures of the lateral column of the elbow involve radial head fractures or capitellum fractures. As the biomechanics of the elbow have become better understood, the importance of the radiocapitellar joint in stabilizing the elbow has been emphasized. Preservation of the radial head has gained importance. For nondisplaced radial head fractures, good results are generally obtained with a short period of immobilization followed by early range of motion. In managing displaced radial head fractures, improved techniques and more versatile instrumentation have helped make preservation more feasible. Excellent results can be achieved with ORIF. In cases in which ORIF is impossible, prosthetic replacement of the radial head is a sound alternative. Successful results have been obtained with arthroplasty, and with second-generation modular systems, the facility of performing this procedure should increase. Treatment of capitellar fractures has also benefited from improved fixation systems. If the fragment is large enough, reduction and fixation with small screws or Kirschner wires have had good success. Excision works well in patients with fragments that are too small or not amenable to fixation, especially if the other structures of the medial elbow and forearm axis are competent.     

A bipolar radial head prosthesis after comminuted radial head fractures: indications,treatment and outcome after 5 years

The treatment of comminuted fractures of the radial head with concomitant injuries of the ulnar complex by resection of the radial head usually does not provide satisfactory long-term results. Other than joint instability in the elbow and a limited range of motion, radius proximalisation in the sense of ulnocarpal impingement, osteoarthritis and pain in the elbow have been described. Between 1995 and 1997, 11 radial head prostheses were implanted in ten patients who had sustained a comminuted fracture of the radial head with concomitant injury to the ulnar complex. A follow-up survey was conducted with the patients on average 5 years after the injury. Eight patients with nine implants participated in the follow-up, one patient had died and another refused to participate but declared that he did not suffer from any impairment. According to the Morrey score, two of the results were found to be very good, five to be good, one to be fair and one to be poor. Despite the severe injuries sustained by the elbow, neither joint instability in the elbow nor proximalisation of the radius, cubitus valgus, ulnar nerve syndrome, nor loosening of the prosthesis were found in any of the patients. In the event of comminuted fractures of the radial head which are impossible to reconstruct by osteosynthesis and which occur with concomitant ulnar ligamentous or osseous injury, the implantation of a prosthesis is preferred over the resection of the head of the radius.     

Arthroplasty with a metal radial head for unreconstructible fractures of the radial head

BACKGROUND: Treatment of unreconstructible comminuted fractures of the radial head remains controversial. There is limited information on the outcome of management of these injuries with arthroplasty with a metal radial head implant. METHODS: The functional outcomes of arthroplasties with a metal radial head implant for the treatment of twenty-five displaced, unreconstructible fractures of the radial head in twenty-four consecutive patients (mean age, fifty-four years) were evaluated at a mean of thirty-nine months (minimum, two years). There were ten Mason type-III and fifteen Mason-Johnston type-IV injuries. Two of these injuries were isolated, and twenty-three were associated with other elbow fractures and/or ligamentous injuries. RESULTS: At the time of follow-up, Short Form-36 (SF-36) summary scores suggested that overall health-related quality of life was within the normal range (physical component = 47 +/- 10, and mental component = 49 +/- 13). Other outcome scales indicated mild disability of the upper extremity (Disabilities of the Arm, Shoulder and Hand score = 17 +/- 19), wrist (Patient-Rated Wrist Evaluation score = 17 +/- 21 and Wrist Outcome Score = 60 +/- 10), and elbow (Mayo Elbow Performance Index = 80 +/- 16). According to the Mayo Elbow Performance Index, three results were graded as poor; five, as fair; and seventeen, as good or excellent. The poor and fair outcomes were associated with concomitant injury in two patients, a history of a psychiatric disorder in three, comorbidity in two, a Workers' Compensation claim in two, and litigation in one. Subjective patient satisfaction averaged 9.2 on a scale of 1 to 10. Elbow flexion of the injured extremity averaged 140 degrees +/- 9 degrees; extension, -8 degrees +/- 7 degrees; pronation, 78 degrees +/- 9 degrees; and supination, 68 degrees +/- 10 degrees. A significant loss of elbow flexion and extension and of forearm supination occurred in the affected extremity, which also had significantly less strength of isometric forearm pronation (17%) and supination (18%) as well as significantly less grip strength (p < 0.05). Asymptomatic bone lucencies surrounded the stem of the implant in seventeen of the twenty-five elbows. Valgus stability was restored, and proximal radial migration did not occur. Complications, all of which resolved, included one complex regional pain syndrome, one ulnar neuropathy, one posterior interosseous nerve palsy, one episode of elbow stiffness, and one wound infection. CONCLUSIONS: Patients treated with a metal radial head implant for a severely comminuted radial head fracture will have mild-to-moderate impairment of the physical capability of the elbow and wrist. At the time of short-term follow-up, arthroplasty with a metal radial head implant was found to have been a safe and effective treatment option for patients with an unreconstructible radial head fracture; however, long-term follow-up is still needed.