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Open Reduction and Internal Fixation Versus Prosthetic Replacement for Complex Fractures of the Radial Head
EVIDENCE-BASED MEDICINE Evidence-Based Medicine
Open Reduction and Internal Fixation Versus Prosthetic Replacement for Complex Fractures of the Radial Head Gabriel Clembosky, MD, Jorge G. Boretto, MD THE PATIENT A 50-year-old man had a posterior Monteggia fracture dislocation after a fall he took while playing soccer (Fig. 1). Physical examination showed a swollen, ecchymotic, deformed, and painful upper dominant extremity. No neurovascular compromise was noted. After clinical and radiographic examination, a proximal third metaphyseal ulna fracture and a dislocated, comminuted fracture of the radial head were diagnosed. The fracture was reduced and immobilized in a splint. THE QUESTION Is it better to repair (via open reduction and internal fixation) or to replace (with a prosthesis) a displaced, comminuted fracture of the radial head? CURRENT OPINION Displaced fractures of the radial head are usually associated with other elbow or forearm fractures or ligament injuries. Regardless of the fracture type, the goals of treatment for radial head fractures are to restore forearm and elbow stability, to preserve forearm and elbow motion, and to maintain the relative length of the radius. Many surgeons believe that it is important to preserve the native radial head, whereas others believe that reliable restoration of radiocapitellar contact with a prosthetic radial head may better address the goals of treatment for complex fractures. FromtheHandandUpperExtremitySurgeryDepartment,OrthopedicandTraumatologyService,Hospital Británico de Buenos Aires, Buenos Aires, Argentina; Hand and Upper Extremity Surgery Department,“Prof.Dr.CarlosOttolenghi’s”Institute,OrthopedicandTraumatologyService,HospitalItaliano de Buenos Aires, Buenos Aires, Argentina. Received for publication November 18, 2008; accepted in revised form December 31, 2008. The authors would like to thank Dr. Carlos Zaidenberg for introducing us to use of polymethyl methacrylate spacers in radial head arthroplasty. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Gabriel Clembosky, MD, Pedriel 74, Ciudad de Buenos Aires, C1280AEB, Argentina; e-mail: [email protected]. 0363-5023/09/34A06-0022$36.00/0 doi:10.1016/j.jhsa.2008.12.031
1120 䉬 © Published by Elsevier, Inc. on behalf of the ASSH.
THE EVIDENCE Open reduction and internal fixation Early in the 1990s, King et al. reported the retrospective results of 14 displaced radial head fractures treated by open reduction and internal fixation.1 Of these fractures, 8 were Mason type 2 (part of the head) and 6 were Mason type III (entire head). They noted worse results among Mason type III fractures, largely related to complications such as failure of fixation, loss of reduction, and poor initial reduction. Consequently, they advised open reduction and internal fixation if stable anatomic reduction can be achieved and excision and prosthetic replacement if fracture reduction and fixation are inadequate. Heim described avascular necrosis and nonunion of 6 of 10 complex whole-head fractures after open reduction and internal fixation.2 Ring and colleagues noted that 4 of 15 comminuted type II fractures recovered less than 100° forearm rotation, and 10 patients with type III fractures had failure of fixation or nonunion. Specifically, among the 14 patients with Mason type III fractures with more than 3 articular fragments, 3 had failure of fixation, 6 had nonunion, and 4 recovered less than 100° forearm rotation. Only 1 patient had a satisfactory result.3 In contrast, Ikeda et al. noted 100% union in 13 comminuted fractures treated with low-profile miniplates and bone grafting and better elbow extension, forearm rotation strength, and functional outcomes in patients treated with open reduction and internal fixation than that in a comparison group treated with resection.4 Nalbantoglu et al. evaluated open reduction and internal fixation of 25 Mason type III fractures and found 1 nonunion, 5 implant removals for symptoms, and no differences between patients with (7 fractures) and without (18 fractures) elbow dislocation.5 Koslowsky et al. prospectively evaluated 24 patients with Mason type III fractures treated with a new fixation device with 100% union, and 86% had a good or
COMPLEX RADIAL HEAD FRACTURES
1121
poor result in 12 patients with complex fractures an average of 5 years after implantation of a Judet prosthesis.11 Prosthetic replacement Regarding a prosthesis with an intentionally loose, The anatomy of the radial head is difficult to reproduce smooth stem (spacer arthroplasty), one study described precisely with a prosthesis.7–9 Consequently, most pros12 excellent, 4 good, 6 fair, and 2 poor results in 26 theses are designed to move and adapt to the complex patients with unrepairable Mason type III fractures at an anatomy, either with a ceaverage of 25 months after mented or press-fit stem with a EDUCATIONAL OBJECTIVES fracture.17 Thirteen patients mobile head or via an unce- ● Describe the pharmacology of Acetaminophen had some radiographic lumented mobile stem.10–14 ● State the benefits of combining Acetaminophen with other medications cency around the stem of the Biomechanical data suggest ● Define the differences between Acetaminophen and NSAIDs in term of prosthesis. Another study rethat neither bipolar head prosported 13 excellent, 9 good, actions, indications, and contraindications theses nor monoblock prosthe- ● 3 fair, and 2 poor results Identify the risk factors for Acetaminophen toxicity ses restore valgus stability in a among 27 patients with Mamedial collateral ligament–d- To claim your 2 hours of CME credits, you must take an online test. Visit son type II (11 patients) and eficient elbow.15 However, http://www.assh.org/professionals/jhs for instructions on accessing the Mason type III (16 patients) most clinical studies have test. A $20 fee will be charged. fractures treated with loose shown that replacement of the metal spacer arthroplasty.10 fractured radial head with a prosthesis helps to restore Seventeen (63%) patients had radiographic lucency stability of the elbow and forearm, even in cases in which around the stem, but this did not correlate with pain. In the collateral ligaments are not repaired.11,12 a third study, Harrington et al. reported 12 excellent, 4 Concerning the bipolar prosthesis, Judet et al. regood, 2 fair, and 2 poor results an average of 12 years ported good functional results in 5 patients an average after surgery.12 All patients demonstrated radiolucency of 49 months after a Mason type III radial head fracture around the stem of the prosthesis, and 4 requested without elbow dislocation.16 Popovic et al. described 4 removal of the prosthesis to treat pain. The arc of excellent, 4 good, 2 fair, and 1 poor result in 11 patients flexion– extension averaged 113°, and the arc of pronatreated with the Judet prosthesis for complex radial tion–supination averaged 139°. head fractures associated with elbow dislocation.14 AnBecause our hospital cannot afford to stock metal radial head prostheses and because most patients in our other study reported 6 excellent, 4 good, 1 fair, and 1
FIGURE 1: Anteroposterior and lateral radiographs showing a posterior Monteggia fracture dislocation.
JHS 䉬 Vol A, July–August
Evidence-Based Medicine
excellent result according to the Broberg and Morrey score at an average of 2 years after surgery.6
1122
COMPLEX RADIAL HEAD FRACTURES
Evidence-Based Medicine
country cannot afford them, we perform loose spacer arthroplasty using a custom spacer made of polymethyl methacrylate (PMMA) cement. An average of 56 months after treatment of 21 Mason type III fractures with a PMMA spacer, we documented 9 excellent, 7 good, and 5 fair results.18 Four spacers were removed to treat complaints of pain, and 4 fractured at the stem but did not require removal. The main complication associated with radial head replacement is the “overstuffing” of the radiocapitellar joint due to the insertion of a prosthesis that is too long.19 This wears down the articular cartilage and causes elbow subluxation.20 SHORTCOMINGS OF THE EVIDENCE AND DIRECTIONS FOR FUTURE RESEARCH Current evidence is limited to small cohort studies, and there exist no randomized trials. Recent reports are from enthusiasts of a given technique, sometimes the developers of a device,6,16,17 and it is not clear that consistent inclusion and exclusion criteria are used. Surgical techniques and implants continue to evolve. We do not know much about the long-term consequences of the contact between cartilage and the prosthesis,12 and there is little evidence to guide the decision between a loose or fixed monoblock prosthesis and a fixed bipolar prosthesis.10 –13 Also insufficient data exist regarding materials issues (eg, metal, pyrocarbon, and methacrylate). Longitudinal prospective studies of patients with radial head replacement are needed to evaluate the longterm results of the consequences of the contact between cartilage and prosthesis and the long-term consequences of a mobile prosthesis. Prospective randomized studies comparing the results of open reduction and internal fixation and radial head replacement and between different types of prostheses would be helpful but will likely need to be done as multicenter trials. Studies of low-cost custom spacers made of PMMA may confirm that this is the best option in less wealthy countries. CURRENT CONCEPTS We attempt to repair all comminuted fractures of the radial head, as experimental evidence has shown that radial head arthroplasty cannot restore normal valgus stability when the medial collateral ligament is deficient. However, if stable and reliable fixation cannot be achieved, there is a definite risk of early failure and of later nonunion, which can contribute to limited motion and to forearm or elbow instability. When faced with these complicated comminuted fractures, arthroplasty
produces consistent results and is more straightforward than open reduction and internal fixation. A PMMA radial head spacer has provided us an economical and useful resource for treating complex radial head fractures when open reduction and internal fixation is technically impossible and when the patient cannot afford a commercial metal prosthesis. REFERENCES 1. King GJ, Evans DC, Kellam JF. Open reduction and internal fixation of radial head fractures. J Orthop Trauma 1991;5:21–28. 2. Heim U. [Combined fractures of the radius and the ulna at the elbow level in the adult. Analysis of 120 cases after more than 1 year]. Rev Chir Orthop Reparatrice Appar Mot 1998;84:142–153. 3. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg 2002;84A:1811– 1815. 4. Ikeda M, Sugiyama K, Kang C, Takagaki T, Oka Y. Comminuted fractures of the radial head. Comparison of resection and internal fixation. J Bone Joint Surg 2005;87A:76 – 84. 5. Nalbantoglu U, Kocaoglu B, Gereli A, Aktas S, Guven O. Open reduction and internal fixation of Mason type III radial head fractures with and without an associated elbow dislocation. J Hand Surg 2007;32A:1560 –1568. 6. Koslowsky TC, Mader K, Gausepohl T, Pennig D. Reconstruction of Mason type-III and type-IV radial head fractures with a new fixation device: 23 patients followed 1-4 years. Acta Orthop 2007;78:151– 156. 7. van Riet RP, Van Glabbeek F, Neale PG, Bortier H, An KN, O’Driscoll SW. The noncircular shape of the radial head. J Hand Surg 2003;28A:972–978. 8. King GJ, Zarzour ZD, Patterson SD, Johnson JA. An anthropometric study of the radial head: implications in the design of a prosthesis. J Arthroplasty 2001;16:112–116. 9. Beredjiklian PK, Nalbantoglu U, Potter HG, Hotchkiss RN. Prosthetic radial head components and proximal radial morphology: a mismatch. J Shoulder Elbow Surg 1999;8:471– 475. 10. Doornberg JN, Parisien R, van Duijn PJ, Ring D. Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. J Bone Joint Surg 2007;89A:1075–1080. 11. Dotzis A, Cochu G, Mabit C, Charissoux JL, Arnaud JP. Comminuted fractures of the radial head treated by the Judet floating radial head prosthesis. J Bone Joint Surg 2006;88B:760 –764. 12. Harrington IJ, Sekyi-Otu A, Barrington TW, Evans DC, Tuli V. The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: a long-term review. J Trauma 2001;50:46 –52. 13. Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ. Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Joint Surg 2001;83A:1201–1211. 14. Popovic N, Gillet P, Rodriguez A, Lemaire R. Fracture of the radial head with associated elbow dislocation: results of treatment using a floating radial head prosthesis. J Orthop Trauma 2000;14:171–177. 15. 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 2001;83A:1829 – 1834. 16. Judet T, Garreau de Loubresse C, Piriou P, Charnley G. A floating prosthesis for radial-head fractures. J Bone Joint Surg 1996;78B: 244 –249. 17. Grewal R, MacDermid JC, Faber KJ, Drosdowech DS, King GJ. Comminuted radial head fractures treated with a modular metallic radial head arthroplasty. Study of outcomes. J Bone Joint Surg 2006;88A:2192–2200.
JHS 䉬 Vol A, July–August
18. Clembosky GA. Espaciador de cemento ortopédico como remplazo de cúpula radial. Rev Asoc Argent Ortop Traumatol 2005;70:113–119. 19. Van Riet RP, Van Glabbeek F, Verborgt O, Gielen J. Capitellar erosion caused by a metal radial head prosthesis. A case report. J Bone Joint Surg 2004;86A:1061–1064.
1123
20. Van Glabbeek F, Van Riet RP, Baumfeld JA, Neale PG, O’Driscoll SW, Morrey BF, et al. Detrimental effects of overstuffing or understuffing with a radial head replacement in the medial collateral-ligament deficient elbow. J Bone Joint Surg 2004;86A:2629 –2635.
JHS 䉬 Vol A, July–August
Evidence-Based Medicine
COMPLEX RADIAL HEAD FRACTURES
Open Reduction and Internal Fixation Versus Prosthetic Replacement for Complex Fractures of the Radial Head Gabriel Clembosky, MD, Jorge G. Boretto, MD THE PATIENT A 50-year-old man had a posterior Monteggia fracture dislocation after a fall he took while playing soccer (Fig. 1). Physical examination showed a swollen, ecchymotic, deformed, and painful upper dominant extremity. No neurovascular compromise was noted. After clinical and radiographic examination, a proximal third metaphyseal ulna fracture and a dislocated, comminuted fracture of the radial head were diagnosed. The fracture was reduced and immobilized in a splint. THE QUESTION Is it better to repair (via open reduction and internal fixation) or to replace (with a prosthesis) a displaced, comminuted fracture of the radial head? CURRENT OPINION Displaced fractures of the radial head are usually associated with other elbow or forearm fractures or ligament injuries. Regardless of the fracture type, the goals of treatment for radial head fractures are to restore forearm and elbow stability, to preserve forearm and elbow motion, and to maintain the relative length of the radius. Many surgeons believe that it is important to preserve the native radial head, whereas others believe that reliable restoration of radiocapitellar contact with a prosthetic radial head may better address the goals of treatment for complex fractures. FromtheHandandUpperExtremitySurgeryDepartment,OrthopedicandTraumatologyService,Hospital Británico de Buenos Aires, Buenos Aires, Argentina; Hand and Upper Extremity Surgery Department,“Prof.Dr.CarlosOttolenghi’s”Institute,OrthopedicandTraumatologyService,HospitalItaliano de Buenos Aires, Buenos Aires, Argentina. Received for publication November 18, 2008; accepted in revised form December 31, 2008. The authors would like to thank Dr. Carlos Zaidenberg for introducing us to use of polymethyl methacrylate spacers in radial head arthroplasty. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Gabriel Clembosky, MD, Pedriel 74, Ciudad de Buenos Aires, C1280AEB, Argentina; e-mail: [email protected]. 0363-5023/09/34A06-0022$36.00/0 doi:10.1016/j.jhsa.2008.12.031
1120 䉬 © Published by Elsevier, Inc. on behalf of the ASSH.
THE EVIDENCE Open reduction and internal fixation Early in the 1990s, King et al. reported the retrospective results of 14 displaced radial head fractures treated by open reduction and internal fixation.1 Of these fractures, 8 were Mason type 2 (part of the head) and 6 were Mason type III (entire head). They noted worse results among Mason type III fractures, largely related to complications such as failure of fixation, loss of reduction, and poor initial reduction. Consequently, they advised open reduction and internal fixation if stable anatomic reduction can be achieved and excision and prosthetic replacement if fracture reduction and fixation are inadequate. Heim described avascular necrosis and nonunion of 6 of 10 complex whole-head fractures after open reduction and internal fixation.2 Ring and colleagues noted that 4 of 15 comminuted type II fractures recovered less than 100° forearm rotation, and 10 patients with type III fractures had failure of fixation or nonunion. Specifically, among the 14 patients with Mason type III fractures with more than 3 articular fragments, 3 had failure of fixation, 6 had nonunion, and 4 recovered less than 100° forearm rotation. Only 1 patient had a satisfactory result.3 In contrast, Ikeda et al. noted 100% union in 13 comminuted fractures treated with low-profile miniplates and bone grafting and better elbow extension, forearm rotation strength, and functional outcomes in patients treated with open reduction and internal fixation than that in a comparison group treated with resection.4 Nalbantoglu et al. evaluated open reduction and internal fixation of 25 Mason type III fractures and found 1 nonunion, 5 implant removals for symptoms, and no differences between patients with (7 fractures) and without (18 fractures) elbow dislocation.5 Koslowsky et al. prospectively evaluated 24 patients with Mason type III fractures treated with a new fixation device with 100% union, and 86% had a good or
COMPLEX RADIAL HEAD FRACTURES
1121
poor result in 12 patients with complex fractures an average of 5 years after implantation of a Judet prosthesis.11 Prosthetic replacement Regarding a prosthesis with an intentionally loose, The anatomy of the radial head is difficult to reproduce smooth stem (spacer arthroplasty), one study described precisely with a prosthesis.7–9 Consequently, most pros12 excellent, 4 good, 6 fair, and 2 poor results in 26 theses are designed to move and adapt to the complex patients with unrepairable Mason type III fractures at an anatomy, either with a ceaverage of 25 months after mented or press-fit stem with a EDUCATIONAL OBJECTIVES fracture.17 Thirteen patients mobile head or via an unce- ● Describe the pharmacology of Acetaminophen had some radiographic lumented mobile stem.10–14 ● State the benefits of combining Acetaminophen with other medications cency around the stem of the Biomechanical data suggest ● Define the differences between Acetaminophen and NSAIDs in term of prosthesis. Another study rethat neither bipolar head prosported 13 excellent, 9 good, actions, indications, and contraindications theses nor monoblock prosthe- ● 3 fair, and 2 poor results Identify the risk factors for Acetaminophen toxicity ses restore valgus stability in a among 27 patients with Mamedial collateral ligament–d- To claim your 2 hours of CME credits, you must take an online test. Visit son type II (11 patients) and eficient elbow.15 However, http://www.assh.org/professionals/jhs for instructions on accessing the Mason type III (16 patients) most clinical studies have test. A $20 fee will be charged. fractures treated with loose shown that replacement of the metal spacer arthroplasty.10 fractured radial head with a prosthesis helps to restore Seventeen (63%) patients had radiographic lucency stability of the elbow and forearm, even in cases in which around the stem, but this did not correlate with pain. In the collateral ligaments are not repaired.11,12 a third study, Harrington et al. reported 12 excellent, 4 Concerning the bipolar prosthesis, Judet et al. regood, 2 fair, and 2 poor results an average of 12 years ported good functional results in 5 patients an average after surgery.12 All patients demonstrated radiolucency of 49 months after a Mason type III radial head fracture around the stem of the prosthesis, and 4 requested without elbow dislocation.16 Popovic et al. described 4 removal of the prosthesis to treat pain. The arc of excellent, 4 good, 2 fair, and 1 poor result in 11 patients flexion– extension averaged 113°, and the arc of pronatreated with the Judet prosthesis for complex radial tion–supination averaged 139°. head fractures associated with elbow dislocation.14 AnBecause our hospital cannot afford to stock metal radial head prostheses and because most patients in our other study reported 6 excellent, 4 good, 1 fair, and 1
FIGURE 1: Anteroposterior and lateral radiographs showing a posterior Monteggia fracture dislocation.
JHS 䉬 Vol A, July–August
Evidence-Based Medicine
excellent result according to the Broberg and Morrey score at an average of 2 years after surgery.6
1122
COMPLEX RADIAL HEAD FRACTURES
Evidence-Based Medicine
country cannot afford them, we perform loose spacer arthroplasty using a custom spacer made of polymethyl methacrylate (PMMA) cement. An average of 56 months after treatment of 21 Mason type III fractures with a PMMA spacer, we documented 9 excellent, 7 good, and 5 fair results.18 Four spacers were removed to treat complaints of pain, and 4 fractured at the stem but did not require removal. The main complication associated with radial head replacement is the “overstuffing” of the radiocapitellar joint due to the insertion of a prosthesis that is too long.19 This wears down the articular cartilage and causes elbow subluxation.20 SHORTCOMINGS OF THE EVIDENCE AND DIRECTIONS FOR FUTURE RESEARCH Current evidence is limited to small cohort studies, and there exist no randomized trials. Recent reports are from enthusiasts of a given technique, sometimes the developers of a device,6,16,17 and it is not clear that consistent inclusion and exclusion criteria are used. Surgical techniques and implants continue to evolve. We do not know much about the long-term consequences of the contact between cartilage and the prosthesis,12 and there is little evidence to guide the decision between a loose or fixed monoblock prosthesis and a fixed bipolar prosthesis.10 –13 Also insufficient data exist regarding materials issues (eg, metal, pyrocarbon, and methacrylate). Longitudinal prospective studies of patients with radial head replacement are needed to evaluate the longterm results of the consequences of the contact between cartilage and prosthesis and the long-term consequences of a mobile prosthesis. Prospective randomized studies comparing the results of open reduction and internal fixation and radial head replacement and between different types of prostheses would be helpful but will likely need to be done as multicenter trials. Studies of low-cost custom spacers made of PMMA may confirm that this is the best option in less wealthy countries. CURRENT CONCEPTS We attempt to repair all comminuted fractures of the radial head, as experimental evidence has shown that radial head arthroplasty cannot restore normal valgus stability when the medial collateral ligament is deficient. However, if stable and reliable fixation cannot be achieved, there is a definite risk of early failure and of later nonunion, which can contribute to limited motion and to forearm or elbow instability. When faced with these complicated comminuted fractures, arthroplasty
produces consistent results and is more straightforward than open reduction and internal fixation. A PMMA radial head spacer has provided us an economical and useful resource for treating complex radial head fractures when open reduction and internal fixation is technically impossible and when the patient cannot afford a commercial metal prosthesis. REFERENCES 1. King GJ, Evans DC, Kellam JF. Open reduction and internal fixation of radial head fractures. J Orthop Trauma 1991;5:21–28. 2. Heim U. [Combined fractures of the radius and the ulna at the elbow level in the adult. Analysis of 120 cases after more than 1 year]. Rev Chir Orthop Reparatrice Appar Mot 1998;84:142–153. 3. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg 2002;84A:1811– 1815. 4. Ikeda M, Sugiyama K, Kang C, Takagaki T, Oka Y. Comminuted fractures of the radial head. Comparison of resection and internal fixation. J Bone Joint Surg 2005;87A:76 – 84. 5. Nalbantoglu U, Kocaoglu B, Gereli A, Aktas S, Guven O. Open reduction and internal fixation of Mason type III radial head fractures with and without an associated elbow dislocation. J Hand Surg 2007;32A:1560 –1568. 6. Koslowsky TC, Mader K, Gausepohl T, Pennig D. Reconstruction of Mason type-III and type-IV radial head fractures with a new fixation device: 23 patients followed 1-4 years. Acta Orthop 2007;78:151– 156. 7. van Riet RP, Van Glabbeek F, Neale PG, Bortier H, An KN, O’Driscoll SW. The noncircular shape of the radial head. J Hand Surg 2003;28A:972–978. 8. King GJ, Zarzour ZD, Patterson SD, Johnson JA. An anthropometric study of the radial head: implications in the design of a prosthesis. J Arthroplasty 2001;16:112–116. 9. Beredjiklian PK, Nalbantoglu U, Potter HG, Hotchkiss RN. Prosthetic radial head components and proximal radial morphology: a mismatch. J Shoulder Elbow Surg 1999;8:471– 475. 10. Doornberg JN, Parisien R, van Duijn PJ, Ring D. Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. J Bone Joint Surg 2007;89A:1075–1080. 11. Dotzis A, Cochu G, Mabit C, Charissoux JL, Arnaud JP. Comminuted fractures of the radial head treated by the Judet floating radial head prosthesis. J Bone Joint Surg 2006;88B:760 –764. 12. Harrington IJ, Sekyi-Otu A, Barrington TW, Evans DC, Tuli V. The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: a long-term review. J Trauma 2001;50:46 –52. 13. Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ. Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Joint Surg 2001;83A:1201–1211. 14. Popovic N, Gillet P, Rodriguez A, Lemaire R. Fracture of the radial head with associated elbow dislocation: results of treatment using a floating radial head prosthesis. J Orthop Trauma 2000;14:171–177. 15. 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 2001;83A:1829 – 1834. 16. Judet T, Garreau de Loubresse C, Piriou P, Charnley G. A floating prosthesis for radial-head fractures. J Bone Joint Surg 1996;78B: 244 –249. 17. Grewal R, MacDermid JC, Faber KJ, Drosdowech DS, King GJ. Comminuted radial head fractures treated with a modular metallic radial head arthroplasty. Study of outcomes. J Bone Joint Surg 2006;88A:2192–2200.
JHS 䉬 Vol A, July–August
18. Clembosky GA. Espaciador de cemento ortopédico como remplazo de cúpula radial. Rev Asoc Argent Ortop Traumatol 2005;70:113–119. 19. Van Riet RP, Van Glabbeek F, Verborgt O, Gielen J. Capitellar erosion caused by a metal radial head prosthesis. A case report. J Bone Joint Surg 2004;86A:1061–1064.
1123
20. Van Glabbeek F, Van Riet RP, Baumfeld JA, Neale PG, O’Driscoll SW, Morrey BF, et al. Detrimental effects of overstuffing or understuffing with a radial head replacement in the medial collateral-ligament deficient elbow. J Bone Joint Surg 2004;86A:2629 –2635.
JHS 䉬 Vol A, July–August
Evidence-Based Medicine
COMPLEX RADIAL HEAD FRACTURES