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Management of comminuted radial head fractures with replacement arthroplasty
Hand Clin 20 (2004) 429–441
Management of comminuted radial head fractures with replacement arthroplasty Graham J.W. King, MD, MSc, FRCSC The Hand and Upper Limb Centre, St. Joseph’s Health Centre, Division Of Orthopaedic Surgery, University Of Western Ontario, 268 Grosvenor Street, London, Ontario, Canada N6A 4L6
Historically most radial head fractures were treated nonoperatively or with radial head excision [1–16]. In recent years, advances in the design and materials of internal fixation devices and better surgical techniques have permitted many patients with displaced radial head fractures to undergo successful open reduction and internal fixation (ORIF) [17–38]. The management of comminuted displaced radial head and neck fractures with ORIF has been less predictable, particularly when there are more than three fragments [39]. Failed ORIF caused by avascular necrosis, nonunion, or fragment displacement usually leads to articular injury to the capitellum and radial notch of the ulna. Stiffness and pain frequently require further surgery, often with less than satisfactory outcomes. In the author’s experience radial head replacement in the setting of failed internal fixation typically does not result in a pain-free elbow, likely because of the damaged cartilage surface articulating with the radial head implant. Primary radial head replacement is preferred, suggesting that the intraoperative decision to fix or replace the radial head is critical to optimize treatment outcome. Speed first reported the use of a metallic radial head arthroplasty in 1941 [40]. Although acrylic was used with some early success, it was not durable [41,42]. Silicone implants gained widespread use in the 1970s and early 1980s [17,43–53]. In recent years increasing concerns regarding wear, particulate debris, and fracture of silicone implants have resulted in a resurgence of interest
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in metallic radial head implant arthroplasty [40,54–62]. Modular and bipolar metallic implants recently have become available, facilitating implantation and providing improved sizing options for a closer match to patient anatomy [63–66].
Anatomy and biomechanics The radial head has a complex and highly variable morphology [65,67]. The radial head provides a circular concave dish that articulates with the spherical capitellum. The articular dish is offset variably from the axis of the radial neck. The articulation with the radial notch of the ulna results in a cam effect during forearm rotation that displaces the radial shaft somewhat radially during pronation [68,69]. Most radial heads have a somewhat elliptical shape that varies considerably between patients. A modular implant is desirable for an optimal fit because of the poor correlation between the size of the radial head and the medullary canal of the radial neck [70]. The radiocapitellar articulation is important for load transfer and stability of the elbow and forearm. Sixty percent of the load that passes across the elbow is borne by radial head [71]. Up to three times body weight can be transmitted to the radiocapitellar joint during strenuous activities [72,73]. These forces may reach nine times body weight following excision of the radial head because of the increase in tension in the medial collateral ligament concentrating the forces on the articulation of the lateral aspect of the coronoid with the lateral portion of the trochlea [72]. The radial head is an important valgus stabilizer of the elbow in the setting of an incompetent
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medial collateral ligament [74–78]. The kinematics and stability of the elbow also are altered by radial head excision in the setting of intact collateral ligaments [79,80]. Radial head replacement with metallic prostheses improves the stability of elbows with intact and deficient medial or lateral collateral ligaments [74,77,80]. Posterolateral rotational instability of the elbow is aggravated by excision of the radial head as a consequence of the loss of capture of the articulating dish of the radial head by the capitellum and a diminished tensioning effect on the lateral collateral ligament [81,82]. Axial forearm stability also is improved by metallic radial head prostheses in the setting of an interosseous ligament disruption [83]. Metallic radial head replacements are superior to silicone in restoring axial and valgus stability [74,83–86].
fragment excision is indicated for small unreconstructable fractures that do not articulate with the proximal radial ulnar joint or impair elbow stability. Displaced radial head fractures that are too comminuted to be reduced anatomically and fixed reliably with ORIF and that are too large to consider fragment excision (fracture involving greater than one quarter of the radial head) should be managed by radial head excision or arthroplasty. Patients who are known to have or are likely to have an associated ligamentous injury of the elbow or forearm should be managed with radial head arthroplasty. Given that most patients with comminuted isolated displaced radial head fractures have an associated soft tissue injury, radial head excision without replacement is indicated uncommonly in the management of acute traumatic elbow injuries.
Associated injuries Comminuted displaced radial head fractures usually are associated with injuries to the medial and lateral collateral ligaments or the interosseous ligament. Johansson reported medial collateral ligament or capsular disruptions in 85% of patients with comminuted radial head fractures [87]. Davidson et al found that all patients with a comminuted radial head fracture had an injury to the medial collateral ligament of the elbow or the interosseous ligament of the forearm (91% and 9%, respectively) [88]. More displaced comminuted radial head fractures are likely of higher energy, and therefore have a greater incidence of associated ligamentous injuries. Elbow dislocations and associated fractures of the coronoid, olecranon, and capitellum further impair elbow stability in patients with a concomitant radial head fracture.
Indications for radial head arthroplasty in elbow trauma The indications for surgical management of radial head fractures are controversial. Fragment size, number, displacement, and bone quality influence decision-making regarding the optimal management. Associated injuries, a block to motion, and crepitus are also important factors to consider. Good results have been reported following ORIF for selected noncomminuted displaced radial head fractures that are incongruous, block rotation, or have crepitus. Radial head
Classification of radial head fractures Classification systems for radial head fractures are based on fracture morphology as judged by plain radiographs or intraoperative findings. Mason classified radial head fractures into three types: I, fissure or marginal sector fractures without displacement; II, marginal sector fractures with displacement; and III, comminuted fractures involving the whole head [9]. This classification has moderate to poor intra- and interobserver reproducibility based on plain radiographs [89]. Mason II fractures often are reclassified to type III during surgery because of additional fracture segments being found that are not appreciated on plain radiographs [26]. A management-based classification was described as follows by Hotchkiss [24]: I, undisplaced or minimally displaced (<2 mm) small marginal fracture of the head or neck with no mechanical block to motion; II, displaced (>2 mm) fracture of the head or neck that is reconstructible with ORIF (may have mechanical block or be incongruous; more than a marginal lip fracture); and III, comminuted fracture of the head or neck that is unreconstructable as judged by radiographs or at surgery. Usually requires excision for movement. Although this classification helps to direct treatment, the distinction between type II and III fractures remains problematic. The decision as to what fracture is reconstructible depends on surgeon experience, available implants, fragment osteoporosis, size, and comminution.
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Evaluation The elbow and forearm should be inspected for ecchymosis suggesting associated ligament injuries. The medial collateral ligament, interosseous ligament, and the distal radioulnar joint should be palpated, as these injuries are often subtle. Even with a careful physical examination, these injuries often are missed. Forearm rotation and elbow flexion–extension should be evaluated. Forearm rotation generally is preserved in patients with radial head fractures but sometimes may be limited by pain or a mechanical block. Loss of terminal elbow flexion and extension is expected as a consequence of a hemarthrosis. Palpable or auditory crepitus should be noted during forearm rotation. Anteroposterior, lateral, and oblique elbow radiographs usually provide sufficient information for the diagnosis and treatment of radial head fractures. The x-ray beam must be centered on the radiocapitellar joint to ensure a tangential view of the radial head. Because of a high incidence of associated interosseous ligament injuries, bilateral posteroanterior radiographs of both wrists in neutral rotation should be performed to evaluate ulnar variance in patients with wrist discomfort and in those who have a comminuted radial head fracture [90]. Computerized tomography may assist with decision making as to the need for surgery and may assist with preoperative planning for specialized equipment for fracture fixation or prosthetic replacement.
Radial head arthroplasty Monoblock metallic radial head implants make size matching suboptimal and implant insertion difficult because of the need to subluxate the elbow [64]. Modular metallic radial head prostheses have separate heads and stems, allowing improved sizing options and easier implantation. The recommended surgical technique varies somewhat between devices; however, most use a Kocher or extensor muscle splitting approach and either preserve or repair the lateral collateral ligament [90]. Currently available devices include spacer implants, press-fit and ingrowth stems, and bipolar articulations. The author has used a metallic radial head implant over the last 15 years that is axisymmetric in shape and incorporates a smooth stem that can move within the radial neck to optimize articular tracking of the implant on the
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capitellum. The current implant is a modular cobalt-chrome device that has varying head and neck thicknesses and diameters. Some implant designs attempt to achieve stem fixation in the radial neck through the use of cement or surface treatments. Implant placement is critical to avoid a cam effect with forearm rotation that can be expected to some extent because of the axisymmetric anatomy of the normal proximal radius. Abnormal tracking may cause premature capitellar wear because of shearing of the cartilage surface and stem loosening caused by increased loading of the stem–bone interface. A bipolar design may improve articular tracking; however, this situation introduces a potential issue related to implant wear and polyethylene debris and less stabilizing effect in the ligament-deficient elbow [91]. When selecting a radial head implant design, the ease of implant removal also should be considered. The removal of well fixed cemented or ingrowth stems may be problematic. There are no reported studies comparing the clinical outcome of different radial head implant designs. On the basis of biomechanical data demonstrating the important role of the radial head in load transfer and stability and the known high incidence of concomitant ligamentous injuries with comminuted radial head fractures, the author currently routinely replaces the radial head in the setting of an unreconstructable fracture. Given the variable results of radial head excision at long-term follow-up [4,6,8,10,92–103] and the encouraging medium-term results of metallic radial head arthroplasty [55,56,59,60,62], this issue clearly requires further study.
Technical aspects The patient is placed in the supine or lateral decubitus position on the operating table and a general or regional anesthesia is administered. Prophylactic intravenous antibiotics are administered. The author prefers a midline posterior elbow incision made just lateral to the tip of the olecranon. This extensile incision reduces cutaneous nerve injuries and provides access to the radial head, coronoid, medial, and lateral collateral ligaments if needed [104,105]. In the author’s experience, posterior incisions are cosmetically more acceptable than standard laterally placed incisions. A full thickness lateral flap is elevated on the deep fascia.
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The fascial interval between the anconeus and extensor carpi ulnaris (Kocher interval) [91] is identified by noting the diverging direction of the muscle groups and small vascular perforators that exit at this interval. The forearm is maintained in pronation during the surgical approach to move the posterior interosseous nerve more distal and medial [106,107]. The extensor carpi ulnaris is elevated slightly anteriorly off the underlying lateral collateral ligament and the radial collateral and annular ligaments are incised longitudinally at the midaxis of the radial head (Fig. 1). Dissection should stay anterior to the lateral ulnar collateral ligament to prevent the development of varus and posterolateral rotatory stability of the elbow [108– 110]. To better expose the anterior half of the radial head and facilitate implant placement, the humeral origin of the radial collateral ligament and the overlying extensor muscles are elevated anteriorly off the lateral epicondyle. If further exposure is needed, release of the posterior component of the lateral collateral ligament can be considered, but careful ligament repair is required at the end of the procedure to treat the
Fig. 1. Lateral collateral ligament anatomy. The radial collateral ligament arises from the lateral epicondyle and inserts into the annular ligament. The lateral ulnar collateral ligament also arises from the lateral epicondyle and inserts into the supinator crest of the ulna, just distal to the annular ligament. The dotted line represents the optimal location to gain access to the radial head during surgery while avoiding detachment of the lateral ulnar collateral ligament, a key varus and posterolateral stabilizer of the elbow. (From Wright Medical Technology, Inc.; with permission.)
resulting instability. Humeral avulsion of the lateral collateral ligament and common extensor muscles from the lateral epicondyle is noted commonly in patients following radial head fractures and is a constant finding in patients with a concomitant elbow dislocation, simplifying surgical exposure of the radial head [110]. In these circumstances the radial head is visualized easily after opening the fascia of the Kocher interval, at which point a bald lateral epicondyle is evident. The fragments of the radial head are removed and reassembled to ensure all pieces are accounted for; use of an image intensifier may be helpful. A minimal amount of radial neck is removed with an oscillating saw at a right angle to the medullary canal to make a smooth surface for seating of the implant. The appropriate diameter and height of the radial head implant is determined using the reassembled native head for comparison. Avoid overstuffing the radiocapitellar joint space by choosing a radial head that is not too thick. A careful comparison of the trial implants with the native head should avoid this problem, which may be associated with elbow stiffness, capitellar wear, and pain from excessive pressure. Inserting the head trial in the elbow performs a further check of the appropriate implant thickness. The radial neck is delivered laterally using a homan retractor carefully placed around the posterior aspect of the proximal radial neck. An anteriorly-based retractor should not be used because of the risk for injury to the posterior interosseous nerve. The medullary canal of the radial neck is reamed using hand rasps until cortical contact is encountered with a goal to achieve a non-tight fit of the trial stem. A trial head is coupled to the stem and the diameter; height and congruency of the prosthesis are evaluated visually and with an image intensifier. The radial head prosthesis should articulate at the same height as the radial notch of the ulna. The alignment of the distal radioulnar joint is confirmed by ensuring that the ulnar variance is equivalent to the opposite wrist. The lateral and medial portions of the ulnohumeral joint should be of similar width on an anteroposterior fluoroscopic view, confirming that the prosthesis is neither too thick nor too thin, resulting in a varus or valgus alignment of the elbow, respectively. This latter measurement is not always reliable, however, as this relationship varies somewhat between elbows. A contralateral elbow radiograph can be helpful to define normal anatomy if the ulnohumeral joint space is not equal in the injured
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elbow. If the prosthesis is maltracking on the capitellum with forearm rotation, a smaller stem size should be trialed to ensure that the articulation of the radial head with the capitellum is optimal as controlled by the annular ligament and articular congruency and is not dictated by a tight fit of the stem in the proximal radius. The surgical implantation of a monoblock radial head implant (where the head is fixed to the stem) or an assembled modular implant may be difficult in the ligamentously intact elbow. Atraumatic placement of such implants often can be achieved by lateral translation of the proximal radius after division of the annular ligament as previously described using a posteriorly placed homan retractor. In some patients insufficient lateral translation of the proximal radius prevents the insertion of a monoblock or an assembled modular implant. Division and subsequent repair of the lateral ulnar collateral ligament allows posterolateral subluxation of the proximal radius to facilitate implant insertion. Some modular and bipolar implants allow insertion of the stem first, followed by placement of the head onto the stem, with coupling in situ. This feature significantly reduces the required exposure, thereby simplifying the procedure (Fig. 2). Following radial head replacement, the lateral collateral ligament and extensor muscle origins are reattached to the lateral epicondyle. If the posterior half of the lateral collateral ligament is still attached to the lateral epicondyle, then the anterior half of the lateral collateral ligament (the annular ligament and radial collateral ligament) and extensor muscles are repaired to the posterior half using interrupted absorbable sutures. If the lateral collateral ligament and extensor origin have been detached completely either by the injury or by surgical exposure, they should be repaired securely using drill holes through bone and nonabsorbable sutures. Drill holes seem to better tension the repair than suture anchors, because the soft tissues can be drawn more easily toward the attachment site. A single hole is drilled at the axis of motion (the center of the arc of curvature of the capitellum) and connected to a hole placed anterior and posterior to the lateral supracondylar ridge. A locking suture technique is used to gain a secure hold of the lateral collateral ligament and common extensor muscle fascia. The ligament sutures are pulled into the holes drilled in the distal humerus using suture retrievers. The elbow is reduced by pronating the forearm and by avoiding varus forces while tying the sutures.
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Rehabilitation The elbow should be placed through an arc of flexion–extension intraoperatively while carefully evaluating stability in pronation, neutral, and supination following replacement arthroplasty and lateral soft tissue closure as previously described [111]. Pronation is generally beneficial if the lateral ligaments are still somewhat deficient [108], supination if the medial ligaments are deficient [112], and neutral position if both sides are injured. If the elbow is still unstable and subluxates or redislocates at 40( or more of flexion following radial head replacement and repair of the lateral ligament as previously described, a medial skin flap should be developed and the medial collateral ligament and flexor pronator origin should be repaired. The elbow with a stable ligamentous repair should be splinted in extension and elevated for 24–48 hours to diminish swelling, decrease tension on the posterior wound, and minimize the tendency to develop a flexion contracture. In the setting of a more tenuous ligamentous repair or the presence of some residual instability at the end of the operative procedure, the elbow initially should be splinted in 60(–90( of flexion in the optimal position of forearm rotation to maintain stability as outlined previously. Indomethacin, 25 mg three times daily for 3 weeks, has been used in patients undergoing radial head arthroplasty to decrease postoperative pain, reduce swelling, and potentially lower the incidence of heterotopic ossification. The risk for heterotopic ossification may be increased in patients with a concomitant dislocation, those undergoing delayed or repeat surgery, and those with an associated head injury [17,88]. The effectiveness of indomethacin in reducing the incidence and severity of heterotopic ossification of the elbow is unknown. Indomethacin should be avoided in elderly patients, those with a history of peptic ulcer disease, and those with known allergy. Patients with an isolated radial head replacement treated with a lateral ulnar collateral ligament-sparing approach have active range of motion initiated on the day following surgery. A collar and cuff with the elbow maintained at 90( is used between exercises until comfortable. A static progressive extension splint is used at night for 12 weeks to assist in regaining extension. Strengthening commences once fracture union and soft tissue healing is secure, typically 8 weeks postoperatively.
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Patients with associated fractures of the coronoid or with residual ligamentous instability should commence active flexion and extension exercises within a safe arc 1–2 days postoperatively. Flexion–extension exercises are performed with the forearm in the appropriate position of forearm rotation as described previously. Forearm rotation is performed with the elbow maintained in flexion to minimize stress on the medial or lateral ligamentous injuries or repairs. A resting splint is used for 3–6 weeks with the elbow maintained at 90( and the forearm in the appropriate position of forearm rotation. A static progressive night extension splinting program is initiated as ligamentous healing progresses and elbow stability improves, usually at 4–6 weeks postoperatively. Passive stretching is not permitted for 6 weeks to reduce the incidence of heterotopic ossification. Strengthening exercises are initiated 8 weeks postoperatively.
Outcome of radial head arthroplasty Silicone radial head arthroplasty is no longer widely used because of problems with residual elbow instability, late arthritis, implant fracture, and fragmentation [17,43–53,113,114]. The mediumterm results of metallic radial head implants are encouraging; however, the long-term outcome with respect to loosening, capitellar wear, and arthritis has not been reported [40,42,54–56,58– 62]. Moro et al reported the functional outcome of 25 patients managed with a monoblock metallic radial head arthroplasty at an average follow-up of 3.5 years [60]. The results were rated as 17 good or excellent, 5 fair, and 3 poor. Most patients had concomitant injuries, such as a dislocation of the elbow, rupture of the medial or lateral collateral ligament, fracture of the coronoid, or fracture of the proximal ulna. The patients had mild residual strength and motion deficits. No patients required removal of the implant. Harrington et al reported their experience with metallic radial head arthroplasty in 20 patients at an average of 12 years [55].
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The results were excellent or good in 16 and fair or poor in 4. Four patients had removal of the implant. Knight et al reported on 31 patients treated with a Vitallium prosthesis at an average of 4.5 years [59]. There was reliable restoration of stability and prevention of proximal radial migration. There were no prosthetic failures, but two implants were removed for loosening. Smets et al reported the results of a bipolar radial head prosthesis in 15 patients with a mean follow-up of 25 months [62]. There were 10 excellent or good and 3 fair or poor results in the group with acute fractures. In the group with chronic problems there were two fair results. There were no prosthesis failures or signs of loosening. Metallic radial head arthroplasty performed for nonunion, malunion, and failed ORIF also has been helpful in improving elbow and forearm function. In the author’s experience, the results of primary radial head arthroplasty tend to be better than secondary replacement, likely because of capitellar cartilage injury and post-traumatic stiffness causing persistent symptoms (Fig. 3). Complications Implant failure Metallic implants do not have a problem with articular wear of the implant surface; however, the articulation of bipolar implant has polyethylene and therefore is potentially subject to wear and failure of the coupling mechanism [115]. Symptomatic loosening of implants that attempt to achieve uncemented or cemented fixation in the proximal radius has been reported with some designs [116]. Osteoarthritis Osteoarthritis of the capitellum can occur as a consequence of chondral damage from the initial injury, as a consequence of increased loading from a radial head implant, or as persistent elbow instability. This condition seems to be particularly common if the radiocapitellar joint is overstuffed because of an excessively thick implant being inserted. The arthritis also may involve the ulnohumeral articulation. Pain and
b Fig. 2. Radial head arthroplasty for fracture. Anteroposterior and lateral radiographs of a 62-year-old man with a block to forearm rotation following a slip on the ice. The patient had tenderness over the medial collateral ligament and valgus instability on stress testing in the operating room. (A,B) A comminuted radial head fracture is noted, as is a small coronoid fracture. The surgical approach preserved the lateral ulnar collateral ligament, which was still intact. (C) Intraoperative appearance with the Evolvee prosthesis in place (Wright Medical Technology, Inc.). Postoperative anteroposterior and lateral radiographs following radial head replacement. (D,E) The medial collateral ligament and coronoid process fracture were not repaired. The patient achieved a painless, stable elbow with an arc of flexion from 25(–140( and full pro-supination.
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Fig. 3. Radial head arthroplasty for malunion. Anteroposterior and lateral radiographs of a 22-year-old woman 6 months after ORIF of a displaced Monteggia fracture. The radial head and neck fracture was treated nonoperatively. (A,B) The patient had a 40( flexion contracture and no supination. (C,D) Anteroposterior and lateral radiographs following ulnar osteotomy and metallic radial head replacement. The patient achieved a painless, stable elbow with an arc of flexion from 15(–140(, full pronation, and 50( of supination.
stiffness develops as the arthritis becomes more advanced. Debridement, open or arthroscopic, can be helpful in managing mechanical symptoms from loose bodies or osteophytes. Removal of the radial head implant can be helpful if the capitellum is arthritic, the ulnohumeral joint is not too involved, and there is no residual elbow or forearm instability. In the author’s experience, ulnohumeral arthritis tends to progress more rapidly
following removal of a radial head implant and pain relief is frequently incomplete. Total elbow arthroplasty may be required for more generalized post-traumatic elbow arthritis. Nerve injury Posterior interosseous nerve injuries are uncommon following radial head arthroplasty. Risk factors include dissection distal to the radial
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tuberosity and placement of anterior retractors or retractors around the distal radial neck [107,117– 119]. The forearm should be maintained in pronation to increase the distance between the nerve and the surgical dissection [107]. Stiffness and heterotopic bone Stiffness following radial head arthroplasty may be due to capsular contracture, heterotopic ossification, or retained cartilaginous or osseous fragments [9,26,34,120]. Capsular contractures with loss of terminal extension are seen most frequently and usually respond to passive stretching under the supervision of a physical therapist [121] and a static progressive splinting extension splint. A flexion cuff is helpful in regaining terminal flexion. A dynamic pro-supination splint is used for patients with loss of forearm rotation [122]. Turnbuckle splinting instituted 12–16 weeks postoperatively can be useful to regain flexion or extension in patients refractory to standard therapy [123]. Patients who fail therapy and splinting and who are symptomatic because of residual stiffness can be managed reliably by open or arthroscopic capsular release, which restores a functional arc of motion in most patients [124–126]. Loss of forearm rotation tends to be treated less successfully on a delayed basis than loss of flexion–extension, which can be improved even years later. This may be because of secondary contractures of the interosseous ligament or distal radioulnar joint. The author prefers to operate early for persistent loss of rotation, typically at 6 months postoperatively [127,128]. Heterotopic bone can be excised as soon as the cortical margins are well defined and the elbow is noninflammatory [129]. Although some investigators do not use any prophylaxis against recurrent ossification, the author has used this routinely. Patients treated with early excision of heterotopic bone (less than 6 months) usually are treated with a single dose of radiation postoperatively, typically 500 Centigray. Late excision usually is managed using indomethacin. Radiation is reserved for patients with massive heterotopic ossification or those with residual cognitive deficits following a head injury and there is a contraindication or known intolerance to nonsteroidal anti-inflammatories. References [1] Adler JB, Shaftan GW. Radial head fractures, is excision necessary? J Trauma 1962;4:115–36.
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[73] Amis AA, Dowson D, Wright V. Elbow joint force predictions for some strenuous isometric actions. J Biomech 1980;13:765–75. [74] King GJ, Zarzour ZD, Rath DA, Dunning CE, Patterson SD, Johnson JA. Metallic radial head arthroplasty improves valgus stability of the elbow. Clin Orthop 1999;368:114–25. [75] Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med 1983;11:315–9. [76] Morrey BF, Tanaka S, An KN. Valgus stability of the elbow. A definition of primary and secondary constraints. Clin Orthop 1991;265:187–95. [77] Pomianowski S, Morrey BF, Neale PG, Park MJ, O’Driscoll SW, An KN. Contribution of monoblock and bipolar radial head prostheses to valgus stability of the elbow. J Bone Joint Surg [Am] 2001; 83A:1829–34. [78] Schwab GH, Bennett JB, Woods GW, Tullos HS. Biomechanics of elbow instability. The role of the medial collateral ligament. Clin Orthop 1980;146: 42–52. [79] Jensen SL, Olsen BS, Sojbjerg JO. Elbow joint kinematics after excision of the radial head. J Shoulder Elbow Surg 1999;8:238–41. [80] King GJW, Beingessner DM, Gordon KD, Dunning CE, Johnson JA. The influence of radial head excision and replacement on the kinematics and laxity of the elbow with and without ligamentous injury. American Shoulder and Elbow Surgeons 19th Annual Meeting. Pebble Beach, California. October 30–November 2, 2002. [81] Beingessner DM, Dunning CE, Beingessner CJ, Johnson JA, King GJW. The effect of radial head fracture size on radiocapitellar joint stability. Clin Biomech 2003;18:677–81. [82] O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg [Am] 1991;73:440–6. [83] Sellman DC, Seitz WH Jr, Postak PD, Greenwald AS. Reconstructive strategies for radioulnar dissociation: a biomechanical study. J Orthop Trauma 1995;9:516–22. [84] Hotchkiss RN, An KN, Sowa DT, Basta S, Weiland AJ. An anatomic and mechanical study of the interosseous membrane of the forearm: pathomechanics of proximal migration of the radius. J Hand Surg 1989;14:256–61. [85] Hotchkiss R, Weiland A. Valgus stability of the elbow. J Orthop Res 1987;5:372–7. [86] Pribyl CR, Kester MA, Cook SD, Edmunds JO, Brunet ME. The effect of the radial head excision and prosthetic radial head replacement on resisting valgus stress at the elbow. Orthopedics 1986;9: 723–6. [87] Johansson O. Capsular and ligament injuries of the elbow joint. A clinical and arthrographic study. Acta Chir Scand 1962;287(Suppl): S5–71.
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Management of comminuted radial head fractures with replacement arthroplasty Graham J.W. King, MD, MSc, FRCSC The Hand and Upper Limb Centre, St. Joseph’s Health Centre, Division Of Orthopaedic Surgery, University Of Western Ontario, 268 Grosvenor Street, London, Ontario, Canada N6A 4L6
Historically most radial head fractures were treated nonoperatively or with radial head excision [1–16]. In recent years, advances in the design and materials of internal fixation devices and better surgical techniques have permitted many patients with displaced radial head fractures to undergo successful open reduction and internal fixation (ORIF) [17–38]. The management of comminuted displaced radial head and neck fractures with ORIF has been less predictable, particularly when there are more than three fragments [39]. Failed ORIF caused by avascular necrosis, nonunion, or fragment displacement usually leads to articular injury to the capitellum and radial notch of the ulna. Stiffness and pain frequently require further surgery, often with less than satisfactory outcomes. In the author’s experience radial head replacement in the setting of failed internal fixation typically does not result in a pain-free elbow, likely because of the damaged cartilage surface articulating with the radial head implant. Primary radial head replacement is preferred, suggesting that the intraoperative decision to fix or replace the radial head is critical to optimize treatment outcome. Speed first reported the use of a metallic radial head arthroplasty in 1941 [40]. Although acrylic was used with some early success, it was not durable [41,42]. Silicone implants gained widespread use in the 1970s and early 1980s [17,43–53]. In recent years increasing concerns regarding wear, particulate debris, and fracture of silicone implants have resulted in a resurgence of interest
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in metallic radial head implant arthroplasty [40,54–62]. Modular and bipolar metallic implants recently have become available, facilitating implantation and providing improved sizing options for a closer match to patient anatomy [63–66].
Anatomy and biomechanics The radial head has a complex and highly variable morphology [65,67]. The radial head provides a circular concave dish that articulates with the spherical capitellum. The articular dish is offset variably from the axis of the radial neck. The articulation with the radial notch of the ulna results in a cam effect during forearm rotation that displaces the radial shaft somewhat radially during pronation [68,69]. Most radial heads have a somewhat elliptical shape that varies considerably between patients. A modular implant is desirable for an optimal fit because of the poor correlation between the size of the radial head and the medullary canal of the radial neck [70]. The radiocapitellar articulation is important for load transfer and stability of the elbow and forearm. Sixty percent of the load that passes across the elbow is borne by radial head [71]. Up to three times body weight can be transmitted to the radiocapitellar joint during strenuous activities [72,73]. These forces may reach nine times body weight following excision of the radial head because of the increase in tension in the medial collateral ligament concentrating the forces on the articulation of the lateral aspect of the coronoid with the lateral portion of the trochlea [72]. The radial head is an important valgus stabilizer of the elbow in the setting of an incompetent
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medial collateral ligament [74–78]. The kinematics and stability of the elbow also are altered by radial head excision in the setting of intact collateral ligaments [79,80]. Radial head replacement with metallic prostheses improves the stability of elbows with intact and deficient medial or lateral collateral ligaments [74,77,80]. Posterolateral rotational instability of the elbow is aggravated by excision of the radial head as a consequence of the loss of capture of the articulating dish of the radial head by the capitellum and a diminished tensioning effect on the lateral collateral ligament [81,82]. Axial forearm stability also is improved by metallic radial head prostheses in the setting of an interosseous ligament disruption [83]. Metallic radial head replacements are superior to silicone in restoring axial and valgus stability [74,83–86].
fragment excision is indicated for small unreconstructable fractures that do not articulate with the proximal radial ulnar joint or impair elbow stability. Displaced radial head fractures that are too comminuted to be reduced anatomically and fixed reliably with ORIF and that are too large to consider fragment excision (fracture involving greater than one quarter of the radial head) should be managed by radial head excision or arthroplasty. Patients who are known to have or are likely to have an associated ligamentous injury of the elbow or forearm should be managed with radial head arthroplasty. Given that most patients with comminuted isolated displaced radial head fractures have an associated soft tissue injury, radial head excision without replacement is indicated uncommonly in the management of acute traumatic elbow injuries.
Associated injuries Comminuted displaced radial head fractures usually are associated with injuries to the medial and lateral collateral ligaments or the interosseous ligament. Johansson reported medial collateral ligament or capsular disruptions in 85% of patients with comminuted radial head fractures [87]. Davidson et al found that all patients with a comminuted radial head fracture had an injury to the medial collateral ligament of the elbow or the interosseous ligament of the forearm (91% and 9%, respectively) [88]. More displaced comminuted radial head fractures are likely of higher energy, and therefore have a greater incidence of associated ligamentous injuries. Elbow dislocations and associated fractures of the coronoid, olecranon, and capitellum further impair elbow stability in patients with a concomitant radial head fracture.
Indications for radial head arthroplasty in elbow trauma The indications for surgical management of radial head fractures are controversial. Fragment size, number, displacement, and bone quality influence decision-making regarding the optimal management. Associated injuries, a block to motion, and crepitus are also important factors to consider. Good results have been reported following ORIF for selected noncomminuted displaced radial head fractures that are incongruous, block rotation, or have crepitus. Radial head
Classification of radial head fractures Classification systems for radial head fractures are based on fracture morphology as judged by plain radiographs or intraoperative findings. Mason classified radial head fractures into three types: I, fissure or marginal sector fractures without displacement; II, marginal sector fractures with displacement; and III, comminuted fractures involving the whole head [9]. This classification has moderate to poor intra- and interobserver reproducibility based on plain radiographs [89]. Mason II fractures often are reclassified to type III during surgery because of additional fracture segments being found that are not appreciated on plain radiographs [26]. A management-based classification was described as follows by Hotchkiss [24]: I, undisplaced or minimally displaced (<2 mm) small marginal fracture of the head or neck with no mechanical block to motion; II, displaced (>2 mm) fracture of the head or neck that is reconstructible with ORIF (may have mechanical block or be incongruous; more than a marginal lip fracture); and III, comminuted fracture of the head or neck that is unreconstructable as judged by radiographs or at surgery. Usually requires excision for movement. Although this classification helps to direct treatment, the distinction between type II and III fractures remains problematic. The decision as to what fracture is reconstructible depends on surgeon experience, available implants, fragment osteoporosis, size, and comminution.
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Evaluation The elbow and forearm should be inspected for ecchymosis suggesting associated ligament injuries. The medial collateral ligament, interosseous ligament, and the distal radioulnar joint should be palpated, as these injuries are often subtle. Even with a careful physical examination, these injuries often are missed. Forearm rotation and elbow flexion–extension should be evaluated. Forearm rotation generally is preserved in patients with radial head fractures but sometimes may be limited by pain or a mechanical block. Loss of terminal elbow flexion and extension is expected as a consequence of a hemarthrosis. Palpable or auditory crepitus should be noted during forearm rotation. Anteroposterior, lateral, and oblique elbow radiographs usually provide sufficient information for the diagnosis and treatment of radial head fractures. The x-ray beam must be centered on the radiocapitellar joint to ensure a tangential view of the radial head. Because of a high incidence of associated interosseous ligament injuries, bilateral posteroanterior radiographs of both wrists in neutral rotation should be performed to evaluate ulnar variance in patients with wrist discomfort and in those who have a comminuted radial head fracture [90]. Computerized tomography may assist with decision making as to the need for surgery and may assist with preoperative planning for specialized equipment for fracture fixation or prosthetic replacement.
Radial head arthroplasty Monoblock metallic radial head implants make size matching suboptimal and implant insertion difficult because of the need to subluxate the elbow [64]. Modular metallic radial head prostheses have separate heads and stems, allowing improved sizing options and easier implantation. The recommended surgical technique varies somewhat between devices; however, most use a Kocher or extensor muscle splitting approach and either preserve or repair the lateral collateral ligament [90]. Currently available devices include spacer implants, press-fit and ingrowth stems, and bipolar articulations. The author has used a metallic radial head implant over the last 15 years that is axisymmetric in shape and incorporates a smooth stem that can move within the radial neck to optimize articular tracking of the implant on the
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capitellum. The current implant is a modular cobalt-chrome device that has varying head and neck thicknesses and diameters. Some implant designs attempt to achieve stem fixation in the radial neck through the use of cement or surface treatments. Implant placement is critical to avoid a cam effect with forearm rotation that can be expected to some extent because of the axisymmetric anatomy of the normal proximal radius. Abnormal tracking may cause premature capitellar wear because of shearing of the cartilage surface and stem loosening caused by increased loading of the stem–bone interface. A bipolar design may improve articular tracking; however, this situation introduces a potential issue related to implant wear and polyethylene debris and less stabilizing effect in the ligament-deficient elbow [91]. When selecting a radial head implant design, the ease of implant removal also should be considered. The removal of well fixed cemented or ingrowth stems may be problematic. There are no reported studies comparing the clinical outcome of different radial head implant designs. On the basis of biomechanical data demonstrating the important role of the radial head in load transfer and stability and the known high incidence of concomitant ligamentous injuries with comminuted radial head fractures, the author currently routinely replaces the radial head in the setting of an unreconstructable fracture. Given the variable results of radial head excision at long-term follow-up [4,6,8,10,92–103] and the encouraging medium-term results of metallic radial head arthroplasty [55,56,59,60,62], this issue clearly requires further study.
Technical aspects The patient is placed in the supine or lateral decubitus position on the operating table and a general or regional anesthesia is administered. Prophylactic intravenous antibiotics are administered. The author prefers a midline posterior elbow incision made just lateral to the tip of the olecranon. This extensile incision reduces cutaneous nerve injuries and provides access to the radial head, coronoid, medial, and lateral collateral ligaments if needed [104,105]. In the author’s experience, posterior incisions are cosmetically more acceptable than standard laterally placed incisions. A full thickness lateral flap is elevated on the deep fascia.
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The fascial interval between the anconeus and extensor carpi ulnaris (Kocher interval) [91] is identified by noting the diverging direction of the muscle groups and small vascular perforators that exit at this interval. The forearm is maintained in pronation during the surgical approach to move the posterior interosseous nerve more distal and medial [106,107]. The extensor carpi ulnaris is elevated slightly anteriorly off the underlying lateral collateral ligament and the radial collateral and annular ligaments are incised longitudinally at the midaxis of the radial head (Fig. 1). Dissection should stay anterior to the lateral ulnar collateral ligament to prevent the development of varus and posterolateral rotatory stability of the elbow [108– 110]. To better expose the anterior half of the radial head and facilitate implant placement, the humeral origin of the radial collateral ligament and the overlying extensor muscles are elevated anteriorly off the lateral epicondyle. If further exposure is needed, release of the posterior component of the lateral collateral ligament can be considered, but careful ligament repair is required at the end of the procedure to treat the
Fig. 1. Lateral collateral ligament anatomy. The radial collateral ligament arises from the lateral epicondyle and inserts into the annular ligament. The lateral ulnar collateral ligament also arises from the lateral epicondyle and inserts into the supinator crest of the ulna, just distal to the annular ligament. The dotted line represents the optimal location to gain access to the radial head during surgery while avoiding detachment of the lateral ulnar collateral ligament, a key varus and posterolateral stabilizer of the elbow. (From Wright Medical Technology, Inc.; with permission.)
resulting instability. Humeral avulsion of the lateral collateral ligament and common extensor muscles from the lateral epicondyle is noted commonly in patients following radial head fractures and is a constant finding in patients with a concomitant elbow dislocation, simplifying surgical exposure of the radial head [110]. In these circumstances the radial head is visualized easily after opening the fascia of the Kocher interval, at which point a bald lateral epicondyle is evident. The fragments of the radial head are removed and reassembled to ensure all pieces are accounted for; use of an image intensifier may be helpful. A minimal amount of radial neck is removed with an oscillating saw at a right angle to the medullary canal to make a smooth surface for seating of the implant. The appropriate diameter and height of the radial head implant is determined using the reassembled native head for comparison. Avoid overstuffing the radiocapitellar joint space by choosing a radial head that is not too thick. A careful comparison of the trial implants with the native head should avoid this problem, which may be associated with elbow stiffness, capitellar wear, and pain from excessive pressure. Inserting the head trial in the elbow performs a further check of the appropriate implant thickness. The radial neck is delivered laterally using a homan retractor carefully placed around the posterior aspect of the proximal radial neck. An anteriorly-based retractor should not be used because of the risk for injury to the posterior interosseous nerve. The medullary canal of the radial neck is reamed using hand rasps until cortical contact is encountered with a goal to achieve a non-tight fit of the trial stem. A trial head is coupled to the stem and the diameter; height and congruency of the prosthesis are evaluated visually and with an image intensifier. The radial head prosthesis should articulate at the same height as the radial notch of the ulna. The alignment of the distal radioulnar joint is confirmed by ensuring that the ulnar variance is equivalent to the opposite wrist. The lateral and medial portions of the ulnohumeral joint should be of similar width on an anteroposterior fluoroscopic view, confirming that the prosthesis is neither too thick nor too thin, resulting in a varus or valgus alignment of the elbow, respectively. This latter measurement is not always reliable, however, as this relationship varies somewhat between elbows. A contralateral elbow radiograph can be helpful to define normal anatomy if the ulnohumeral joint space is not equal in the injured
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elbow. If the prosthesis is maltracking on the capitellum with forearm rotation, a smaller stem size should be trialed to ensure that the articulation of the radial head with the capitellum is optimal as controlled by the annular ligament and articular congruency and is not dictated by a tight fit of the stem in the proximal radius. The surgical implantation of a monoblock radial head implant (where the head is fixed to the stem) or an assembled modular implant may be difficult in the ligamentously intact elbow. Atraumatic placement of such implants often can be achieved by lateral translation of the proximal radius after division of the annular ligament as previously described using a posteriorly placed homan retractor. In some patients insufficient lateral translation of the proximal radius prevents the insertion of a monoblock or an assembled modular implant. Division and subsequent repair of the lateral ulnar collateral ligament allows posterolateral subluxation of the proximal radius to facilitate implant insertion. Some modular and bipolar implants allow insertion of the stem first, followed by placement of the head onto the stem, with coupling in situ. This feature significantly reduces the required exposure, thereby simplifying the procedure (Fig. 2). Following radial head replacement, the lateral collateral ligament and extensor muscle origins are reattached to the lateral epicondyle. If the posterior half of the lateral collateral ligament is still attached to the lateral epicondyle, then the anterior half of the lateral collateral ligament (the annular ligament and radial collateral ligament) and extensor muscles are repaired to the posterior half using interrupted absorbable sutures. If the lateral collateral ligament and extensor origin have been detached completely either by the injury or by surgical exposure, they should be repaired securely using drill holes through bone and nonabsorbable sutures. Drill holes seem to better tension the repair than suture anchors, because the soft tissues can be drawn more easily toward the attachment site. A single hole is drilled at the axis of motion (the center of the arc of curvature of the capitellum) and connected to a hole placed anterior and posterior to the lateral supracondylar ridge. A locking suture technique is used to gain a secure hold of the lateral collateral ligament and common extensor muscle fascia. The ligament sutures are pulled into the holes drilled in the distal humerus using suture retrievers. The elbow is reduced by pronating the forearm and by avoiding varus forces while tying the sutures.
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Rehabilitation The elbow should be placed through an arc of flexion–extension intraoperatively while carefully evaluating stability in pronation, neutral, and supination following replacement arthroplasty and lateral soft tissue closure as previously described [111]. Pronation is generally beneficial if the lateral ligaments are still somewhat deficient [108], supination if the medial ligaments are deficient [112], and neutral position if both sides are injured. If the elbow is still unstable and subluxates or redislocates at 40( or more of flexion following radial head replacement and repair of the lateral ligament as previously described, a medial skin flap should be developed and the medial collateral ligament and flexor pronator origin should be repaired. The elbow with a stable ligamentous repair should be splinted in extension and elevated for 24–48 hours to diminish swelling, decrease tension on the posterior wound, and minimize the tendency to develop a flexion contracture. In the setting of a more tenuous ligamentous repair or the presence of some residual instability at the end of the operative procedure, the elbow initially should be splinted in 60(–90( of flexion in the optimal position of forearm rotation to maintain stability as outlined previously. Indomethacin, 25 mg three times daily for 3 weeks, has been used in patients undergoing radial head arthroplasty to decrease postoperative pain, reduce swelling, and potentially lower the incidence of heterotopic ossification. The risk for heterotopic ossification may be increased in patients with a concomitant dislocation, those undergoing delayed or repeat surgery, and those with an associated head injury [17,88]. The effectiveness of indomethacin in reducing the incidence and severity of heterotopic ossification of the elbow is unknown. Indomethacin should be avoided in elderly patients, those with a history of peptic ulcer disease, and those with known allergy. Patients with an isolated radial head replacement treated with a lateral ulnar collateral ligament-sparing approach have active range of motion initiated on the day following surgery. A collar and cuff with the elbow maintained at 90( is used between exercises until comfortable. A static progressive extension splint is used at night for 12 weeks to assist in regaining extension. Strengthening commences once fracture union and soft tissue healing is secure, typically 8 weeks postoperatively.
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Patients with associated fractures of the coronoid or with residual ligamentous instability should commence active flexion and extension exercises within a safe arc 1–2 days postoperatively. Flexion–extension exercises are performed with the forearm in the appropriate position of forearm rotation as described previously. Forearm rotation is performed with the elbow maintained in flexion to minimize stress on the medial or lateral ligamentous injuries or repairs. A resting splint is used for 3–6 weeks with the elbow maintained at 90( and the forearm in the appropriate position of forearm rotation. A static progressive night extension splinting program is initiated as ligamentous healing progresses and elbow stability improves, usually at 4–6 weeks postoperatively. Passive stretching is not permitted for 6 weeks to reduce the incidence of heterotopic ossification. Strengthening exercises are initiated 8 weeks postoperatively.
Outcome of radial head arthroplasty Silicone radial head arthroplasty is no longer widely used because of problems with residual elbow instability, late arthritis, implant fracture, and fragmentation [17,43–53,113,114]. The mediumterm results of metallic radial head implants are encouraging; however, the long-term outcome with respect to loosening, capitellar wear, and arthritis has not been reported [40,42,54–56,58– 62]. Moro et al reported the functional outcome of 25 patients managed with a monoblock metallic radial head arthroplasty at an average follow-up of 3.5 years [60]. The results were rated as 17 good or excellent, 5 fair, and 3 poor. Most patients had concomitant injuries, such as a dislocation of the elbow, rupture of the medial or lateral collateral ligament, fracture of the coronoid, or fracture of the proximal ulna. The patients had mild residual strength and motion deficits. No patients required removal of the implant. Harrington et al reported their experience with metallic radial head arthroplasty in 20 patients at an average of 12 years [55].
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The results were excellent or good in 16 and fair or poor in 4. Four patients had removal of the implant. Knight et al reported on 31 patients treated with a Vitallium prosthesis at an average of 4.5 years [59]. There was reliable restoration of stability and prevention of proximal radial migration. There were no prosthetic failures, but two implants were removed for loosening. Smets et al reported the results of a bipolar radial head prosthesis in 15 patients with a mean follow-up of 25 months [62]. There were 10 excellent or good and 3 fair or poor results in the group with acute fractures. In the group with chronic problems there were two fair results. There were no prosthesis failures or signs of loosening. Metallic radial head arthroplasty performed for nonunion, malunion, and failed ORIF also has been helpful in improving elbow and forearm function. In the author’s experience, the results of primary radial head arthroplasty tend to be better than secondary replacement, likely because of capitellar cartilage injury and post-traumatic stiffness causing persistent symptoms (Fig. 3). Complications Implant failure Metallic implants do not have a problem with articular wear of the implant surface; however, the articulation of bipolar implant has polyethylene and therefore is potentially subject to wear and failure of the coupling mechanism [115]. Symptomatic loosening of implants that attempt to achieve uncemented or cemented fixation in the proximal radius has been reported with some designs [116]. Osteoarthritis Osteoarthritis of the capitellum can occur as a consequence of chondral damage from the initial injury, as a consequence of increased loading from a radial head implant, or as persistent elbow instability. This condition seems to be particularly common if the radiocapitellar joint is overstuffed because of an excessively thick implant being inserted. The arthritis also may involve the ulnohumeral articulation. Pain and
b Fig. 2. Radial head arthroplasty for fracture. Anteroposterior and lateral radiographs of a 62-year-old man with a block to forearm rotation following a slip on the ice. The patient had tenderness over the medial collateral ligament and valgus instability on stress testing in the operating room. (A,B) A comminuted radial head fracture is noted, as is a small coronoid fracture. The surgical approach preserved the lateral ulnar collateral ligament, which was still intact. (C) Intraoperative appearance with the Evolvee prosthesis in place (Wright Medical Technology, Inc.). Postoperative anteroposterior and lateral radiographs following radial head replacement. (D,E) The medial collateral ligament and coronoid process fracture were not repaired. The patient achieved a painless, stable elbow with an arc of flexion from 25(–140( and full pro-supination.
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Fig. 3. Radial head arthroplasty for malunion. Anteroposterior and lateral radiographs of a 22-year-old woman 6 months after ORIF of a displaced Monteggia fracture. The radial head and neck fracture was treated nonoperatively. (A,B) The patient had a 40( flexion contracture and no supination. (C,D) Anteroposterior and lateral radiographs following ulnar osteotomy and metallic radial head replacement. The patient achieved a painless, stable elbow with an arc of flexion from 15(–140(, full pronation, and 50( of supination.
stiffness develops as the arthritis becomes more advanced. Debridement, open or arthroscopic, can be helpful in managing mechanical symptoms from loose bodies or osteophytes. Removal of the radial head implant can be helpful if the capitellum is arthritic, the ulnohumeral joint is not too involved, and there is no residual elbow or forearm instability. In the author’s experience, ulnohumeral arthritis tends to progress more rapidly
following removal of a radial head implant and pain relief is frequently incomplete. Total elbow arthroplasty may be required for more generalized post-traumatic elbow arthritis. Nerve injury Posterior interosseous nerve injuries are uncommon following radial head arthroplasty. Risk factors include dissection distal to the radial
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tuberosity and placement of anterior retractors or retractors around the distal radial neck [107,117– 119]. The forearm should be maintained in pronation to increase the distance between the nerve and the surgical dissection [107]. Stiffness and heterotopic bone Stiffness following radial head arthroplasty may be due to capsular contracture, heterotopic ossification, or retained cartilaginous or osseous fragments [9,26,34,120]. Capsular contractures with loss of terminal extension are seen most frequently and usually respond to passive stretching under the supervision of a physical therapist [121] and a static progressive splinting extension splint. A flexion cuff is helpful in regaining terminal flexion. A dynamic pro-supination splint is used for patients with loss of forearm rotation [122]. Turnbuckle splinting instituted 12–16 weeks postoperatively can be useful to regain flexion or extension in patients refractory to standard therapy [123]. Patients who fail therapy and splinting and who are symptomatic because of residual stiffness can be managed reliably by open or arthroscopic capsular release, which restores a functional arc of motion in most patients [124–126]. Loss of forearm rotation tends to be treated less successfully on a delayed basis than loss of flexion–extension, which can be improved even years later. This may be because of secondary contractures of the interosseous ligament or distal radioulnar joint. The author prefers to operate early for persistent loss of rotation, typically at 6 months postoperatively [127,128]. Heterotopic bone can be excised as soon as the cortical margins are well defined and the elbow is noninflammatory [129]. Although some investigators do not use any prophylaxis against recurrent ossification, the author has used this routinely. Patients treated with early excision of heterotopic bone (less than 6 months) usually are treated with a single dose of radiation postoperatively, typically 500 Centigray. Late excision usually is managed using indomethacin. Radiation is reserved for patients with massive heterotopic ossification or those with residual cognitive deficits following a head injury and there is a contraindication or known intolerance to nonsteroidal anti-inflammatories. References [1] Adler JB, Shaftan GW. Radial head fractures, is excision necessary? J Trauma 1962;4:115–36.
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