- Email: [email protected]
Treatment of Radial Head Fractures and Need for Revision Procedures at 1 and 2 Years
EDITOR’S CHOICE
Treatment of Radial Head Fractures and Need for Revision Procedures at 1 and 2 Years Eli S. Kupperman, MD,* Asher I. Kupperman, MD,* Scott A. Mitchell, MD†
Purpose Optimal treatment strategies for radial head fractures remain a subject of debate. We examined national practice patterns in the management of radial head fractures to determine rates of surgical treatment, type of surgery employed, and the incidence of reoperation. Methods Between 2007 and 2011, we identified patients with radial head fractures along with their associated injuries by International Classification of Diseases, Ninth Revision codes in a national database of orthopedic insurance records. For those who underwent surgery, the type of intervention was identified and each patient was observed to determine whether a subsequent procedure was needed by 1 and 2 years. Chi-square analysis was performed to make comparisons between groups. Results A total of 58,404 radial head fractures were identified between 2007 and 2011; of these, 2,981 underwent surgical treatment (5.1%). Rates of surgical intervention were significantly higher in the context of associated injuries. Among the 2,981 radial head fractures treated surgically, 57.1% underwent open reduction internal fixation (ORIF), 37.9% were treated with radial head arthroplasty, and 4.9% underwent radial head excision. When the surgically treated radial head fracture was associated with a coronoid fracture, elbow dislocation, or proximal ulna fracture, 64.2%, 54.3%, and 47.2% were treated with arthroplasty, respectively, compared with 32.6%, 41.9%, and 52.6% treated with ORIF, respectively. After initial surgical treatment, 12.7% and 14.4% of radial head fractures that underwent ORIF required a secondary surgery at 1 and 2 years, respectively, compared with 8.6% and 10.7% of radial head arthroplasties and 8.3% and 8.4% of resections. Conclusions Rates of arthroplasty were significantly higher in the context of associated injury, particularly in the setting of a coronoid fracture or elbow dislocation. Fractures initially treated with ORIF had a higher rate of revision surgery at both 1 and 2 years after the index procedure compared with arthroplasty. (J Hand Surg Am. 2017;-(-):-e-. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic II. Key words Coronoid fracture, elbow dislocation, olecranon fracture, radial head arthroplasty, radial head fracture.
From the *Department of Orthopaedic Surgery, University of California at Los Angeles, Los Angeles, CA; and the †Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX.
Corresponding author: Eli S. Kupperman, MD, Department of Orthopaedic Surgery, University of California at Los Angeles, 10833 Le Conte Avenue, CHS 76-143, Los Angeles, CA 90095; e-mail: [email protected].
Received for publication July 1, 2016; accepted in revised form October 16, 2017.
0363-5023/17/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2017.10.022
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Ó 2017 ASSH
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Published by Elsevier, Inc. All rights reserved.
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one-third of all fractures around the elbow. They are frequently associated with other elbow injuries.1e4 Traditionally, radial head fractures are classified according to the Mason classification, in which type I are nondisplaced, type II are displaced, type III are comminuted, and type IV are associated with concurrent elbow dislocations.5 In general, types I and II may be treated nonsurgically if no mechanical block to motion is present.6,7 Those who need surgical repair are often treated with open reduction and internal fixation (ORIF). The management of more complex type III and IV fractures remains controversial. Historically, resection of the radial head was used for fractures that could not be reconstructed. However, as complications related to elbow instability, proximal migration of the radius, and ulnohumeral arthrosis after radial head excision have become better understood, this treatment choice has fallen out of favor and preservation of radiocapitellar contact is now advocated.8,9 Whether to repair or replace the radial head elicits considerable debate. Whereas this decision is often determined by fracture morphology and extent of comminution, the presence of associated injuries about the elbow may also influence treatment.10,11 Although many surgeons advocate preserving the radial head whenever possible,12 replacement may become a more attractive option with more complex injuries given improved patient outcomes with replacement as well as the increased exposure to the coronoid process gained during surgery by removal of comminuted head fragments.11,13,14 The purpose of this study was to design the surgical treatment choices of orthopedic surgeons treating patients with radial head fractures in the United States, as well as rates of reoperation within 2 years. Our hypothesis was that most radial head fractures managed surgically are treated with ORIF as opposed to arthroplasty, but that as the injury becomes more complex, such as a concurrent elbow dislocation or fracture, the rate of arthroplasty increases.10,15 In addition, because they are more commonly associated with complex injuries,10 we expected that there would be more revisions for fractures treated with arthroplasty as opposed to ORIF after 1 and 2 years. ADIAL HEAD FRACTURES ACCOUNT FOR
TABLE 1. ICD-9 Code
Diagnosis
813.05
Closed fracture of head of radius
813.06
Closed fracture of neck of radius
813.07
Other and unspecified closed fractures of proximal end of radius
813.08
Closed fracture of radius with ulna, upper end
813.15
Open fracture of head of radius
813.16
Open fracture of neck of radius
813.17
Other and unspecified open fractures of proximal end of radius
813.18
Open fracture of radius with ulna, upper end
832.00
Closed dislocation of elbow, unspecified
832.01
Closed anterior dislocation of elbow
832.02
Closed posterior dislocation of elbow
832.03
Closed medial dislocation of elbow
832.04
Closed lateral dislocation of elbow
832.09
Closed dislocation of elbow, other
832.10
Open dislocation of elbow, unspecified
832.11
Open anterior dislocation of elbow
832.12
Open posterior dislocation of elbow
832.13
Open medial dislocation of elbow
832.14
Open lateral dislocation of elbow
832.19
Open dislocation of elbow, other
813.01
Closed fracture of olecranon process of ulna
813.03
Closed Monteggia fracture
813.04
Other and unspecified closed fractures of proximal end of ulna
813.08
Closed fracture of radius with ulna, upper end
813.10
Open fracture of upper end of forearm, unspecified
813.11
Open fracture of olecranon process of ulna
813.13
Open Monteggia fracture
813.14
Other and unspecified open fractures of proximal end of ulna
813.18
Open fracture of radius with ulna, upper end
813.02
Closed fracture of coronoid process of ulna
813.12
Open fracture of coronoid process of ulna
ICD-9, International Classification of Diseases, Ninth Revision.
patients for whom at least one orthopedic diagnosis code has been recorded using either International Classification of Diseases, Ninth Revision (ICD-9) or Current Procedural Terminology (CPT) codes. We used the PearlDiver database because it allows a query of records from a large number of orthopedic patients from a private payer insurance company across all age groups and locations in the United States, although it is
MATERIALS AND METHODS The private payer arm of the PearlDiver Patient Record Database was searched to identify all patients who sustained a radial head or neck fracture between 2007 and 2011. The PearlDiver database used for this study is an online dataset of national insurance billing records of J Hand Surg Am.
List of ICD-9 Codes
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not necessarily representative of the population. The database is composed of more than 20 million patients. Patients with radial head or neck fractures were identified through ICD-9 codes (813.05-.08, 813.15-.18) (Table 1). These patients were further stratified based on whether they sustained a concomitant injury, identified as an elbow dislocation, a proximal ulna fracture, or a coronoid fracture based on ICD-9 codes submitted concurrently with the radial head fracture diagnosis. To identify elbow dislocations, we used ICD-9 codes 832.00-.04, 832.09-.14, and 832.19. Proximal ulna fractures were identified with ICD-9 codes 813.01, 813.03-.04, 813.08, 813.10-.11, 813.13-.14, and 813.18. Coronoid fractures were identified with ICD-9 codes 813.02 and 813.12 (Table 1). Age was grouped into 10-year age categories from 0 to 10 through ages 60 to 69 years, with a final age group including all patients aged older than 70 years. Operative treatment was divided into 3 treatment types: radial head ORIF, radial head implant arthroplasty, and radial head excision. We used CPT code 24665 to identify patients who underwent ORIF. To identify patients who underwent radial head arthroplasty, CPT codes 24666, 24365, and 24366 were used. Finally, CPT code 24130 was used to identify patients who underwent a radial head resection (Table 2). Patients who received operative treatment were observed for 2 years to determine whether a revision procedure was coded. For patients who were initially treated with ORIF, CPT codes 24665, 24130, 24666, 24635, and 20680 were used to identify those who required subsequent treatment including revision ORIF, radial head excision, radial head arthroplasty, or implant removal. For patients who were initially treated with radial head implant arthroplasty, revisions were identified using CPT codes 24164, 24160, and 20680 to determine which patients required implant removal or revision. Finally, for patients who were initially treated with resection arthroplasty, CPT codes 24666, 24365, and 24366 were used to identify patients who required prosthetic reconstruction. In addition, revision surgeries were identified for each group that had subsequent distal ulna procedures identified with CPT codes 25360, 25390, 25830, 25240, and 25377 (Table 2). Subsequent procedures that fell outside these CPT codes were not identified in the database. For our statistical analysis, we used chi-square test to compare distributions of treatment for radial head fractures by sex and age. In addition, chi-square analysis was used to compare the proportions of patients treated with the different procedures, differences J Hand Surg Am.
TABLE 2.
List of CPT Codes
CPT Code
Procedure
24665
Open treatment of radial head or neck fracture; includes internal fixation or radial head excision when performed
24666
Open treatment of radial head or neck fracture; includes internal fixation or radial head excision when performed with radial head prosthetic replacement
24365
Arthroplasty, radial head
24366
Arthroplasty, radial head; with implant
24130
Excision, radial head
24635
Open treatment of Monteggia-type fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head); includes internal fixation when performed
20680
Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)
24164
Removal of prosthesis; includes debridement and synovectomy when performed; radial head
24160
Removal of prosthesis, includes debridement and synovectomy when performed; humeral and ulnar components
24366
Arthroplasty, radial head; with implant
25360
Osteotomy; ulna
25390
Osteoplasty, radius or ulna; shortening
25830
Arthrodesis, distal radioulnar joint with segmental resection of ulna, with or without bone graft (eg, Sauve-Kapandji procedure)
25240
Excision distal ulna partial or complete (eg, Darrach type or matched resection)
CPT, Current Procedural Terminology.
in treatment chosen based on concomitant injury, and rate of revision based on initial treatment chosen. Significance was set to P < .05 for all analyses. RESULTS Our search identified a total of 58,404 radial head and neck fractures between 2007 and 2011. Of these, 769 were found to have a concomitant coronoid fracture based on ICD-9 coding (1.3%), 2,038 had an associated ipsilateral elbow dislocation (3.5%), and 7,163 had a proximal ulna fracture (12.3%). A total of 2,981 fractures underwent surgical treatment (5.1%). This number was decreased to 3.2% of our database population when the radial head fracture was an isolated injury. When the radial head fracture was associated with a coronoid fracture, 36.3% underwent r
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Treatment Choice by Injury Paern 80.00% 70.00% 60.00%
ORIF
50.00%
Prosthesis
40.00% 30.00%
Resecon
20.00% 10.00% 0.00% All Radial Head Isolated Radial Fractures Head Fractures
Elbow Dislocaons
Coronoid Fractures
Olecranon Fractures
FIGURE 1: Surgical treatment of radial head fractures based on concomitant injury. Buckets are labeled based on the associated injury. ORIF indicates open reduction and internal fixation; prosthesis indicates radial head arthroplasty; and resection indicates radial head resection.
surgical treatment. For patients with concomitant elbow dislocations, 23.0% had surgery. If there was a proximal ulna fracture in addition to the radial head fracture, 9.6% underwent surgery. The choice of surgical treatment differed among groups stratified for associated injuries, as seen in Figure 1. For all radial head fractures treated operatively, 57.1% were treated with ORIF, 37.9% were treated with prosthetic replacement, and 4.9% were treated with resection arthroplasty. In the subset of radial head fractures with a concomitant coronoid fracture, 32.6% were treated by ORIF, compared with 64.2% with prosthetic replacement and 2.5% with radial head resection (P < .05 compared with all radial head fractures). For injuries with associated elbow dislocations, 41.9% of patients underwent ORIF, 54.3% had prosthetic replacement, and 3.4% had resection arthroplasty (P < .05 compared with all radial head fractures). For radial head fractures associated with proximal ulna fractures, 52.6% were treated with ORIF, 47.2% with prosthetic replacement, and 4.1% with radial head resection (P < .05 compared with all radial head fractures). When evaluating surgical treatment of radial head fractures by age, we found that the proportion of fractures treated with prosthetic replacement increased with age whereas the rate of ORIF decreased, as seen in Figure 2. In patients 1-19 years old, 93.2% of patients underwent ORIF, 4.4% had radial head arthroplasty, and 2.5% had resections. From ages 20 to 49 years, 57.3% of patients had ORIF, 38.3% underwent radial head arthroplasty, and 4.5% had resection arthroplasty. Over age 50 years, 41.7% of patients underwent ORIF, 57.9% had radial head arthroplasty, and 6.4% had J Hand Surg Am.
resection arthroplasty. Using the same age groups, the rate of concomitant injuries also increased with increasing age. Whereas only 4.4% of those aged 1 to 19 years had concomitant elbow injuries reported, that number grew to 10.8% in patients aged 20 to 49 years, and 11.5% of those aged over 50 years. We also measured rates of reoperation at 1 and 2 years for patients stratified by injury and surgery type, as shown in Figures 3 and 4. For ORIF, 12.7% were reoperated on by 1 year and 14.4% needed a subsequent procedure within 2 years of surgery. For radial head implant arthroplasty, 8.6% underwent a subsequent procedure by 1 year, and 10.7% by 2 years. For radial head resection, 8.3% underwent reoperation within a year and 8.4% within 2 years. This difference in the rates of additional procedures at 1 and 2 years was statistically significant for ORIF versus radial head arthroplasty (P < .05). When examined based on injury patterns, 10.9% of isolated radial head fractures required subsequent surgery within 1 year, and 12.7% within 2 years. With a concomitant coronoid fracture, those numbers were 13.4% and 11.3%, respectively. For radial head fractures associated with elbow dislocations, subsequent surgery was required for 15.1% and 16.3% at 1 and 2 years, respectively. Reoperation rates were highest in combined radial head and proximal ulna fractures, with subsequent surgeries in 17.1% and 21.3% at 1 and 2 years, respectively. DISCUSSION Most radial head fractures are treated nonsurgically. Of the 58,404 radial head fractures in the current r
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Treatment Choice by Age 100% 90% 80% ORIF
70% 60%
Prosthesis
50% Resecon 40% 30% 20% 10% 0% 1-19 years
20-49 years
50+ years
FIGURE 2: Breakdown by percentage of all surgically treated radial head fractures by treatment type, based on age. ORIF indicates open reduction and internal fixation; prosthesis indicates radial head arthroplasty; and resection indicates radial head resection.
study, only 5.1% underwent surgical treatment. The rate of surgery increased dramatically when associated with concomitant injuries. Over 36% of radial head fractures associated with coronoid fractures, 23% with associated elbow dislocations, and 10% with concurrent proximal ulna fracture underwent surgery. Several factors may have contributed to this pattern. Radial head fractures with large degrees of displacement tend to be associated with more complex injuries about the elbow.16 Increasing fracture displacement likely influences the decision for surgical management. In addition, in the presence of associated bony and/or ligamentous injuries to the elbow, the radial head assumes a more important role in restoring elbow stability and load transfer. The radial head acts as a stabilizer to valgus stress, an anterior buttress against posterior instability, and a longitudinal stabilizer of the forearm. It may be that the goal of restoring radiocapitellar contact drives the decision for surgical intervention.17 We also sought to determine whether concomitant injuries were associated with the surgeon’s choice of surgical treatment. Our data demonstrated that the surgery most commonly performed for isolated radial head fractures was ORIF. This is consistent with the clinical observation that most isolated radial head fractures tend to be lower-energy injuries with less comminution than complex injuries.18 As we hypothesized, the rate of radial head arthroplasty increased when it was associated with concomitant injuries in the elbow. This was most apparent with a concomitant coronoid fracture, for which 64.2% of injuries were treated with radial head arthroplasty J Hand Surg Am.
versus 54.3% with elbow dislocation and 47.2% with proximal ulna fractures. It may be that associated injuries are simply indicators of higher energy trauma with greater degrees of displacement and/or comminution of the radial head. It is also possible that concomitant coronoid fractures led to the largest rate of radial head arthroplasty, not only because of the morphology of the radial head fracture but also because of the relative ease of exposure of the coronoid that radial head arthroplasty allows. With implant arthroplasty, resection of the radial head before implantation of the prosthesis facilitates visualization and access to the coronoid, which would allow both fractures to be treated through a single lateral exposure if necessary. We found that few patients were treated with radial head resection in this study, regardless of the presence of concomitant injury or age. This may in part be due to lack of specificity in CPT coding related to radial head resection. This may also reflect the increased appreciation of the importance of the radial head. Long-term studies also demonstrated high rates of ulnohumeral arthrosis after radial head excision, which highlights the importance of restoring radiocapitellar load transmission.19,20 However, radial head replacement can also lead to arthritis. A retrospective study evaluating patients who underwent either ORIF or radial head replacement for radial head fractures associated with elbow dislocations found increased rates of arthrosis in patients who underwent radial head replacement, although none required revision in medium-term follow-up.21 We also looked at treatment type based on the patient’s age. We hypothesized that younger patients r
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Rate of Revision at 1 Year
Rate of Revision at 2 Years
14%
16%
12%
14%
10%
12%
8%
10% 8%
6%
6%
4%
4% 2%
2% 0% ORIF
Prosthesis
Resecon
0% ORIF
FIGURE 3: Percentage revised by 1 year for all surgically treated radial head fractures based on treatment type. ORIF indicates open reduction and internal fixation; prosthesis indicates radial head arthroplasty; and resection indicates radial head resection.
Resecon
FIGURE 4: Percentage revised by 2 years for all surgically treated radial head fractures based on treatment type. ORIF indicates open reduction and internal fixation; prosthesis indicates radial head arthroplasty; and resection indicates radial head resection.
would be more likely to be treated with ORIF and that rates of radial head arthroplasty would increase as age increased. Our results showed that the rate of arthroplasty was low in the pediatric population and increased to over 50% of surgically treated fractures in patients aged over 50 years. This may reflect concerns regarding capitellar wear and other longterm, implant-related complications that may arise after prosthetic replacement in young patients. In older patients, the trend toward arthroplasty may result from decreased concern regarding long-term wear, or it may reflect difficulty achieving stable internal fixation with diminished bone density. We hypothesized that the rate of subsequent surgery after radial head replacements would be higher than ORIF. However, we found that at both 1 and 2 years, the rate of subsequent surgery for ORIF was higher than the corresponding rate after radial head arthroplasty. We hypothesize that this high revision rate for ORIF may be due to comminuted fractures that might have been better treated with radial head arthroplasty. In the setting of ORIF, elbows in these patients may go on to develop posttraumatic arthritis, hardware irritation, failure of fixation, or osteonecrosis of the radial head. These outcomes could necessitate subsequent surgery after ORIF. It is also possible that there are fewer options for revision of radial head arthroplasty as opposed to internal fixation. Lack of subsequent surgery does not necessarily mean the implant is successful. This result was similar to a recently published study of press-fit radial head arthroplasty that reported no revisions by 30 months, although 40% showed loosening of the prosthesis.22 A long-term outcome study of 119 patients with radial head arthroplasty showed a revision rate of 29% at a mean of 6.7 years.23 Although there is controversy regarding the clinical implications of J Hand Surg Am.
Prosthesis
stem lucencies seen radiographically, it may be that the need for subsequent surgery at 1 to 2 years, as examined in the current study, underestimates implant-related complications that may become clinically more apparent with time.24 There are several limitations to this study. Because this was a database review, we were limited by the data available to us. For example, we did not have radiographs to classify the fracture or clinical outcome data accurately, such as range of motion, pain, or elbow function. We also were unable to identify the type of implants used to assess how internal fixation was achieved. Rather, our only clinical outcome was the need for reoperation. The need for operation can be misleading, as well. We assumed that most operations performed on the elbow in the 2 years after an elbow surgery are revision surgeries of the index operation, but we were not able to detect which subsequent surgeries in the elbow were indeed performed for revision purposes and which were for other reasons. There was also no identifier of laterality in our database, so it possible that a subsequent surgery was performed on the contralateral elbow or even that in addition to the radial head fracture, the concomitant injury identified was from the contralateral side. In addition, the database is not necessarily representative of the population. It is a private database and therefore lacks Medicare data in the older population as well as data from the indigent population. This could have affected the findings of the study because the population in the current study may skew younger than the general population of those sustaining radial head fractures, and the options for care may be different in this private payer population as well. An additional limitation is that the primary data r
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depend on physician coding with ICD-9 and CPT codes. Therefore, our results may have been affected by ambiguity inherent in coding, as well as possible miscoding or a lack of coding. One example is that patients with radial head and coronoid fractures may also have elbow dislocations that were not coded; similarly, those with radial head fractures and elbow dislocation may have coronoid fractures as well. As with any database study, results do not indicate causality, and cannot be used for patient care decisions. Nevertheless, nationwide data from PearlDiver reflects half a decade of practice patterns regarding the treatment of radial head fractures. These descriptive results may help provide preliminary data to motivate future clinical, epidemiological, or clinical effectiveness studies. Our hypothesis was that most isolated radial head fractures that require operative intervention are treated with ORIF as opposed to arthroplasty. We also hypothesized that as the injury becomes more complicated, such as a concurrent elbow dislocation or fracture, the rate of arthroplasty would increase. In addition, we expected that there would be more subsequent operations for fractures treated with arthroplasty as opposed to ORIF after 1 and 2 years. We found that the first 2 hypotheses were consistent with the results of our study but that ORIF was revised more frequently than radial head arthroplasty. Further investigation into practice variations and outcome is warranted.
8. Lindenhovius AL, Felsch Q, Doornberg JN, Ring D, Kloen P. Open reduction and internal fixation compared with excision for unstable displaced fractures of the radial head. J Hand Surg Am. 2007;32(5): 630e636. 9. VanBeek C, Levine W. Radial head—resect, fix, or replace. Oper Tech Orthop. 2010;20:2e10. 10. Ring D. Radial head fracture: open reduction-internal fixation or prosthetic replacement. J Shoulder Elbow Surg. 2011;20(2 suppl): S107eS112. 11. Sun H, Duan J, Li F. Comparison between radial head arthroplasty and open reduction and internal fixation in patients with radial head fractures (modified Mason type III and IV): a meta-analysis. Eur J Orthop Surg Traumatol. 2016;26(3):283e291. 12. Zwingmann J, Welzel M, Dovi-Akue D, Schmal H, Sudkamp NP, Strohm PC. Clinical results after different operative treatment methods of radial head and neck fractures: a systematic review and meta-analysis of clinical outcome. Injury. 2013;44(11):1540e1550. 13. Li N, Chen S. Open reduction and internal-fixation versus radial head replacement in treatment of Mason type III radial head fractures. Eur J Orthop Surg Traumatol. 2014;24(6):851e855. 14. Ruchelsman DE, Christoforou D, Jupiter JB. Fractures of the radial head and neck. J Bone Joint Surg Am. 2013;95(5):469e478. 15. Fowler JR, Goitz RJ. Radial head fractures: indications and outcomes for radial head arthroplasty. Orthop Clin North Am. 2013;44: 425e431. 16. Rineer CA, Guitton TG, Ring D. Radial head fractures: loss of cortical contact is associated with concomitant fracture or dislocation. J Shoulder Elbow Surg. 2010;19(1):21e25. 17. Mckee MD, Pugh DM, Wild LM, Schemitsch EH, King GJ. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures: surgical technique. J Bone Joint Surg Am. 2005;87(suppl 1 part 1):22e32. 18. Kodde IF, Kaas L, van Es N, Mulder PG, van Dijk CN, Eygendaal D. The effect of trauma and patient related factors on radial head fractures and associated injuries in 440 patients. BMC Musculoskelet Disord. 2015;16:135. 19. Antuña SA, Sánchez-Márquez JM, Barco R. Long-term results of radial head resection following isolated radial head fractures in patients younger than forty years old. J Bone Joint Surg Am. 2010;92(3):558e566. 20. Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Nyqvist F, Karlsson MK. Fractures of the radial head and neck treated with radial head excision. J Bone Joint Surg Am. 2004;86(9):1925e1930. 21. Watters TS, Garrigues GE, Ring D, Ruch DS. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Clin Orthop Relat Res. 2014;472(7): 2128e2135. 22. Levy JC, Formaini NT, Kurowicki J. Outcomes and radiographic findings of anatomic press-fit radial head arthroplasty. J Shoulder Elbow Surg. 2016:S1058eS2746. 23. Duckworth AD, Wickramasinghe NR, Clement ND, CourtBrown CM, McQueen MM. Radial head replacement for acute complex fractures: what are the rate and risks factors for revision or removal? Clin Orthop Relat Res. 2014;472(7):2136e2143. 24. Marsh JP, Grewal R, Faber KJ, Drosdowech DS, Athwal GS, King GJ. Radial head fractures treated with modular metallic radial head replacement: outcomes at a mean follow-up of eight years. J Bone Joint Surg Am. 2016;98(7):527e535.
REFERENCES 1. Burkhart KJ, Wegmann K, Muller LP, Gohlke FE. Fractures of the radial head. Hand Clin. 2015;31(4):533e546. 2. Charalambous C, Stanley J, Mills S. Comminuted radial head fractures: aspects of current management. J Shoulder Elbow Surg. 2011;20(6):996e1007. 3. Duckworth AD, Clement ND, Jenkins PJ, Aitken SA, CourtBrown CM, McQueen MM. The epidemiology of radial head and neck fractures. J Hand Surg Am. 2012;37(1):112e119. 4. Kaas L, van Riet R, Vroemen J, Eygendaal D. The epidemiology of radial head fractures. J Shoulder Elbow Surg. 2010;19(4):520e523. 5. Calfee R, Madom I, Weiss A. Radial head arthroplasty. J Hand Surg Am. 2006;31(2):314e321. 6. Pike J, Athwal GS, Faber KJ, King GJ. Radial head fractures—an update. J Hand Surg Am. 2009;34(3):557e565. 7. Yoon A, Athwal GS, Faber KJ, King GJ. Radial head fractures. J Hand Surg Am. 2012;37(12):2626e2634.
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Treatment of Radial Head Fractures and Need for Revision Procedures at 1 and 2 Years Eli S. Kupperman, MD,* Asher I. Kupperman, MD,* Scott A. Mitchell, MD†
Purpose Optimal treatment strategies for radial head fractures remain a subject of debate. We examined national practice patterns in the management of radial head fractures to determine rates of surgical treatment, type of surgery employed, and the incidence of reoperation. Methods Between 2007 and 2011, we identified patients with radial head fractures along with their associated injuries by International Classification of Diseases, Ninth Revision codes in a national database of orthopedic insurance records. For those who underwent surgery, the type of intervention was identified and each patient was observed to determine whether a subsequent procedure was needed by 1 and 2 years. Chi-square analysis was performed to make comparisons between groups. Results A total of 58,404 radial head fractures were identified between 2007 and 2011; of these, 2,981 underwent surgical treatment (5.1%). Rates of surgical intervention were significantly higher in the context of associated injuries. Among the 2,981 radial head fractures treated surgically, 57.1% underwent open reduction internal fixation (ORIF), 37.9% were treated with radial head arthroplasty, and 4.9% underwent radial head excision. When the surgically treated radial head fracture was associated with a coronoid fracture, elbow dislocation, or proximal ulna fracture, 64.2%, 54.3%, and 47.2% were treated with arthroplasty, respectively, compared with 32.6%, 41.9%, and 52.6% treated with ORIF, respectively. After initial surgical treatment, 12.7% and 14.4% of radial head fractures that underwent ORIF required a secondary surgery at 1 and 2 years, respectively, compared with 8.6% and 10.7% of radial head arthroplasties and 8.3% and 8.4% of resections. Conclusions Rates of arthroplasty were significantly higher in the context of associated injury, particularly in the setting of a coronoid fracture or elbow dislocation. Fractures initially treated with ORIF had a higher rate of revision surgery at both 1 and 2 years after the index procedure compared with arthroplasty. (J Hand Surg Am. 2017;-(-):-e-. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic II. Key words Coronoid fracture, elbow dislocation, olecranon fracture, radial head arthroplasty, radial head fracture.
From the *Department of Orthopaedic Surgery, University of California at Los Angeles, Los Angeles, CA; and the †Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX.
Corresponding author: Eli S. Kupperman, MD, Department of Orthopaedic Surgery, University of California at Los Angeles, 10833 Le Conte Avenue, CHS 76-143, Los Angeles, CA 90095; e-mail: [email protected].
Received for publication July 1, 2016; accepted in revised form October 16, 2017.
0363-5023/17/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2017.10.022
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
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one-third of all fractures around the elbow. They are frequently associated with other elbow injuries.1e4 Traditionally, radial head fractures are classified according to the Mason classification, in which type I are nondisplaced, type II are displaced, type III are comminuted, and type IV are associated with concurrent elbow dislocations.5 In general, types I and II may be treated nonsurgically if no mechanical block to motion is present.6,7 Those who need surgical repair are often treated with open reduction and internal fixation (ORIF). The management of more complex type III and IV fractures remains controversial. Historically, resection of the radial head was used for fractures that could not be reconstructed. However, as complications related to elbow instability, proximal migration of the radius, and ulnohumeral arthrosis after radial head excision have become better understood, this treatment choice has fallen out of favor and preservation of radiocapitellar contact is now advocated.8,9 Whether to repair or replace the radial head elicits considerable debate. Whereas this decision is often determined by fracture morphology and extent of comminution, the presence of associated injuries about the elbow may also influence treatment.10,11 Although many surgeons advocate preserving the radial head whenever possible,12 replacement may become a more attractive option with more complex injuries given improved patient outcomes with replacement as well as the increased exposure to the coronoid process gained during surgery by removal of comminuted head fragments.11,13,14 The purpose of this study was to design the surgical treatment choices of orthopedic surgeons treating patients with radial head fractures in the United States, as well as rates of reoperation within 2 years. Our hypothesis was that most radial head fractures managed surgically are treated with ORIF as opposed to arthroplasty, but that as the injury becomes more complex, such as a concurrent elbow dislocation or fracture, the rate of arthroplasty increases.10,15 In addition, because they are more commonly associated with complex injuries,10 we expected that there would be more revisions for fractures treated with arthroplasty as opposed to ORIF after 1 and 2 years. ADIAL HEAD FRACTURES ACCOUNT FOR
TABLE 1. ICD-9 Code
Diagnosis
813.05
Closed fracture of head of radius
813.06
Closed fracture of neck of radius
813.07
Other and unspecified closed fractures of proximal end of radius
813.08
Closed fracture of radius with ulna, upper end
813.15
Open fracture of head of radius
813.16
Open fracture of neck of radius
813.17
Other and unspecified open fractures of proximal end of radius
813.18
Open fracture of radius with ulna, upper end
832.00
Closed dislocation of elbow, unspecified
832.01
Closed anterior dislocation of elbow
832.02
Closed posterior dislocation of elbow
832.03
Closed medial dislocation of elbow
832.04
Closed lateral dislocation of elbow
832.09
Closed dislocation of elbow, other
832.10
Open dislocation of elbow, unspecified
832.11
Open anterior dislocation of elbow
832.12
Open posterior dislocation of elbow
832.13
Open medial dislocation of elbow
832.14
Open lateral dislocation of elbow
832.19
Open dislocation of elbow, other
813.01
Closed fracture of olecranon process of ulna
813.03
Closed Monteggia fracture
813.04
Other and unspecified closed fractures of proximal end of ulna
813.08
Closed fracture of radius with ulna, upper end
813.10
Open fracture of upper end of forearm, unspecified
813.11
Open fracture of olecranon process of ulna
813.13
Open Monteggia fracture
813.14
Other and unspecified open fractures of proximal end of ulna
813.18
Open fracture of radius with ulna, upper end
813.02
Closed fracture of coronoid process of ulna
813.12
Open fracture of coronoid process of ulna
ICD-9, International Classification of Diseases, Ninth Revision.
patients for whom at least one orthopedic diagnosis code has been recorded using either International Classification of Diseases, Ninth Revision (ICD-9) or Current Procedural Terminology (CPT) codes. We used the PearlDiver database because it allows a query of records from a large number of orthopedic patients from a private payer insurance company across all age groups and locations in the United States, although it is
MATERIALS AND METHODS The private payer arm of the PearlDiver Patient Record Database was searched to identify all patients who sustained a radial head or neck fracture between 2007 and 2011. The PearlDiver database used for this study is an online dataset of national insurance billing records of J Hand Surg Am.
List of ICD-9 Codes
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not necessarily representative of the population. The database is composed of more than 20 million patients. Patients with radial head or neck fractures were identified through ICD-9 codes (813.05-.08, 813.15-.18) (Table 1). These patients were further stratified based on whether they sustained a concomitant injury, identified as an elbow dislocation, a proximal ulna fracture, or a coronoid fracture based on ICD-9 codes submitted concurrently with the radial head fracture diagnosis. To identify elbow dislocations, we used ICD-9 codes 832.00-.04, 832.09-.14, and 832.19. Proximal ulna fractures were identified with ICD-9 codes 813.01, 813.03-.04, 813.08, 813.10-.11, 813.13-.14, and 813.18. Coronoid fractures were identified with ICD-9 codes 813.02 and 813.12 (Table 1). Age was grouped into 10-year age categories from 0 to 10 through ages 60 to 69 years, with a final age group including all patients aged older than 70 years. Operative treatment was divided into 3 treatment types: radial head ORIF, radial head implant arthroplasty, and radial head excision. We used CPT code 24665 to identify patients who underwent ORIF. To identify patients who underwent radial head arthroplasty, CPT codes 24666, 24365, and 24366 were used. Finally, CPT code 24130 was used to identify patients who underwent a radial head resection (Table 2). Patients who received operative treatment were observed for 2 years to determine whether a revision procedure was coded. For patients who were initially treated with ORIF, CPT codes 24665, 24130, 24666, 24635, and 20680 were used to identify those who required subsequent treatment including revision ORIF, radial head excision, radial head arthroplasty, or implant removal. For patients who were initially treated with radial head implant arthroplasty, revisions were identified using CPT codes 24164, 24160, and 20680 to determine which patients required implant removal or revision. Finally, for patients who were initially treated with resection arthroplasty, CPT codes 24666, 24365, and 24366 were used to identify patients who required prosthetic reconstruction. In addition, revision surgeries were identified for each group that had subsequent distal ulna procedures identified with CPT codes 25360, 25390, 25830, 25240, and 25377 (Table 2). Subsequent procedures that fell outside these CPT codes were not identified in the database. For our statistical analysis, we used chi-square test to compare distributions of treatment for radial head fractures by sex and age. In addition, chi-square analysis was used to compare the proportions of patients treated with the different procedures, differences J Hand Surg Am.
TABLE 2.
List of CPT Codes
CPT Code
Procedure
24665
Open treatment of radial head or neck fracture; includes internal fixation or radial head excision when performed
24666
Open treatment of radial head or neck fracture; includes internal fixation or radial head excision when performed with radial head prosthetic replacement
24365
Arthroplasty, radial head
24366
Arthroplasty, radial head; with implant
24130
Excision, radial head
24635
Open treatment of Monteggia-type fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head); includes internal fixation when performed
20680
Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)
24164
Removal of prosthesis; includes debridement and synovectomy when performed; radial head
24160
Removal of prosthesis, includes debridement and synovectomy when performed; humeral and ulnar components
24366
Arthroplasty, radial head; with implant
25360
Osteotomy; ulna
25390
Osteoplasty, radius or ulna; shortening
25830
Arthrodesis, distal radioulnar joint with segmental resection of ulna, with or without bone graft (eg, Sauve-Kapandji procedure)
25240
Excision distal ulna partial or complete (eg, Darrach type or matched resection)
CPT, Current Procedural Terminology.
in treatment chosen based on concomitant injury, and rate of revision based on initial treatment chosen. Significance was set to P < .05 for all analyses. RESULTS Our search identified a total of 58,404 radial head and neck fractures between 2007 and 2011. Of these, 769 were found to have a concomitant coronoid fracture based on ICD-9 coding (1.3%), 2,038 had an associated ipsilateral elbow dislocation (3.5%), and 7,163 had a proximal ulna fracture (12.3%). A total of 2,981 fractures underwent surgical treatment (5.1%). This number was decreased to 3.2% of our database population when the radial head fracture was an isolated injury. When the radial head fracture was associated with a coronoid fracture, 36.3% underwent r
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Treatment Choice by Injury Paern 80.00% 70.00% 60.00%
ORIF
50.00%
Prosthesis
40.00% 30.00%
Resecon
20.00% 10.00% 0.00% All Radial Head Isolated Radial Fractures Head Fractures
Elbow Dislocaons
Coronoid Fractures
Olecranon Fractures
FIGURE 1: Surgical treatment of radial head fractures based on concomitant injury. Buckets are labeled based on the associated injury. ORIF indicates open reduction and internal fixation; prosthesis indicates radial head arthroplasty; and resection indicates radial head resection.
surgical treatment. For patients with concomitant elbow dislocations, 23.0% had surgery. If there was a proximal ulna fracture in addition to the radial head fracture, 9.6% underwent surgery. The choice of surgical treatment differed among groups stratified for associated injuries, as seen in Figure 1. For all radial head fractures treated operatively, 57.1% were treated with ORIF, 37.9% were treated with prosthetic replacement, and 4.9% were treated with resection arthroplasty. In the subset of radial head fractures with a concomitant coronoid fracture, 32.6% were treated by ORIF, compared with 64.2% with prosthetic replacement and 2.5% with radial head resection (P < .05 compared with all radial head fractures). For injuries with associated elbow dislocations, 41.9% of patients underwent ORIF, 54.3% had prosthetic replacement, and 3.4% had resection arthroplasty (P < .05 compared with all radial head fractures). For radial head fractures associated with proximal ulna fractures, 52.6% were treated with ORIF, 47.2% with prosthetic replacement, and 4.1% with radial head resection (P < .05 compared with all radial head fractures). When evaluating surgical treatment of radial head fractures by age, we found that the proportion of fractures treated with prosthetic replacement increased with age whereas the rate of ORIF decreased, as seen in Figure 2. In patients 1-19 years old, 93.2% of patients underwent ORIF, 4.4% had radial head arthroplasty, and 2.5% had resections. From ages 20 to 49 years, 57.3% of patients had ORIF, 38.3% underwent radial head arthroplasty, and 4.5% had resection arthroplasty. Over age 50 years, 41.7% of patients underwent ORIF, 57.9% had radial head arthroplasty, and 6.4% had J Hand Surg Am.
resection arthroplasty. Using the same age groups, the rate of concomitant injuries also increased with increasing age. Whereas only 4.4% of those aged 1 to 19 years had concomitant elbow injuries reported, that number grew to 10.8% in patients aged 20 to 49 years, and 11.5% of those aged over 50 years. We also measured rates of reoperation at 1 and 2 years for patients stratified by injury and surgery type, as shown in Figures 3 and 4. For ORIF, 12.7% were reoperated on by 1 year and 14.4% needed a subsequent procedure within 2 years of surgery. For radial head implant arthroplasty, 8.6% underwent a subsequent procedure by 1 year, and 10.7% by 2 years. For radial head resection, 8.3% underwent reoperation within a year and 8.4% within 2 years. This difference in the rates of additional procedures at 1 and 2 years was statistically significant for ORIF versus radial head arthroplasty (P < .05). When examined based on injury patterns, 10.9% of isolated radial head fractures required subsequent surgery within 1 year, and 12.7% within 2 years. With a concomitant coronoid fracture, those numbers were 13.4% and 11.3%, respectively. For radial head fractures associated with elbow dislocations, subsequent surgery was required for 15.1% and 16.3% at 1 and 2 years, respectively. Reoperation rates were highest in combined radial head and proximal ulna fractures, with subsequent surgeries in 17.1% and 21.3% at 1 and 2 years, respectively. DISCUSSION Most radial head fractures are treated nonsurgically. Of the 58,404 radial head fractures in the current r
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Treatment Choice by Age 100% 90% 80% ORIF
70% 60%
Prosthesis
50% Resecon 40% 30% 20% 10% 0% 1-19 years
20-49 years
50+ years
FIGURE 2: Breakdown by percentage of all surgically treated radial head fractures by treatment type, based on age. ORIF indicates open reduction and internal fixation; prosthesis indicates radial head arthroplasty; and resection indicates radial head resection.
study, only 5.1% underwent surgical treatment. The rate of surgery increased dramatically when associated with concomitant injuries. Over 36% of radial head fractures associated with coronoid fractures, 23% with associated elbow dislocations, and 10% with concurrent proximal ulna fracture underwent surgery. Several factors may have contributed to this pattern. Radial head fractures with large degrees of displacement tend to be associated with more complex injuries about the elbow.16 Increasing fracture displacement likely influences the decision for surgical management. In addition, in the presence of associated bony and/or ligamentous injuries to the elbow, the radial head assumes a more important role in restoring elbow stability and load transfer. The radial head acts as a stabilizer to valgus stress, an anterior buttress against posterior instability, and a longitudinal stabilizer of the forearm. It may be that the goal of restoring radiocapitellar contact drives the decision for surgical intervention.17 We also sought to determine whether concomitant injuries were associated with the surgeon’s choice of surgical treatment. Our data demonstrated that the surgery most commonly performed for isolated radial head fractures was ORIF. This is consistent with the clinical observation that most isolated radial head fractures tend to be lower-energy injuries with less comminution than complex injuries.18 As we hypothesized, the rate of radial head arthroplasty increased when it was associated with concomitant injuries in the elbow. This was most apparent with a concomitant coronoid fracture, for which 64.2% of injuries were treated with radial head arthroplasty J Hand Surg Am.
versus 54.3% with elbow dislocation and 47.2% with proximal ulna fractures. It may be that associated injuries are simply indicators of higher energy trauma with greater degrees of displacement and/or comminution of the radial head. It is also possible that concomitant coronoid fractures led to the largest rate of radial head arthroplasty, not only because of the morphology of the radial head fracture but also because of the relative ease of exposure of the coronoid that radial head arthroplasty allows. With implant arthroplasty, resection of the radial head before implantation of the prosthesis facilitates visualization and access to the coronoid, which would allow both fractures to be treated through a single lateral exposure if necessary. We found that few patients were treated with radial head resection in this study, regardless of the presence of concomitant injury or age. This may in part be due to lack of specificity in CPT coding related to radial head resection. This may also reflect the increased appreciation of the importance of the radial head. Long-term studies also demonstrated high rates of ulnohumeral arthrosis after radial head excision, which highlights the importance of restoring radiocapitellar load transmission.19,20 However, radial head replacement can also lead to arthritis. A retrospective study evaluating patients who underwent either ORIF or radial head replacement for radial head fractures associated with elbow dislocations found increased rates of arthrosis in patients who underwent radial head replacement, although none required revision in medium-term follow-up.21 We also looked at treatment type based on the patient’s age. We hypothesized that younger patients r
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Rate of Revision at 1 Year
Rate of Revision at 2 Years
14%
16%
12%
14%
10%
12%
8%
10% 8%
6%
6%
4%
4% 2%
2% 0% ORIF
Prosthesis
Resecon
0% ORIF
FIGURE 3: Percentage revised by 1 year for all surgically treated radial head fractures based on treatment type. ORIF indicates open reduction and internal fixation; prosthesis indicates radial head arthroplasty; and resection indicates radial head resection.
Resecon
FIGURE 4: Percentage revised by 2 years for all surgically treated radial head fractures based on treatment type. ORIF indicates open reduction and internal fixation; prosthesis indicates radial head arthroplasty; and resection indicates radial head resection.
would be more likely to be treated with ORIF and that rates of radial head arthroplasty would increase as age increased. Our results showed that the rate of arthroplasty was low in the pediatric population and increased to over 50% of surgically treated fractures in patients aged over 50 years. This may reflect concerns regarding capitellar wear and other longterm, implant-related complications that may arise after prosthetic replacement in young patients. In older patients, the trend toward arthroplasty may result from decreased concern regarding long-term wear, or it may reflect difficulty achieving stable internal fixation with diminished bone density. We hypothesized that the rate of subsequent surgery after radial head replacements would be higher than ORIF. However, we found that at both 1 and 2 years, the rate of subsequent surgery for ORIF was higher than the corresponding rate after radial head arthroplasty. We hypothesize that this high revision rate for ORIF may be due to comminuted fractures that might have been better treated with radial head arthroplasty. In the setting of ORIF, elbows in these patients may go on to develop posttraumatic arthritis, hardware irritation, failure of fixation, or osteonecrosis of the radial head. These outcomes could necessitate subsequent surgery after ORIF. It is also possible that there are fewer options for revision of radial head arthroplasty as opposed to internal fixation. Lack of subsequent surgery does not necessarily mean the implant is successful. This result was similar to a recently published study of press-fit radial head arthroplasty that reported no revisions by 30 months, although 40% showed loosening of the prosthesis.22 A long-term outcome study of 119 patients with radial head arthroplasty showed a revision rate of 29% at a mean of 6.7 years.23 Although there is controversy regarding the clinical implications of J Hand Surg Am.
Prosthesis
stem lucencies seen radiographically, it may be that the need for subsequent surgery at 1 to 2 years, as examined in the current study, underestimates implant-related complications that may become clinically more apparent with time.24 There are several limitations to this study. Because this was a database review, we were limited by the data available to us. For example, we did not have radiographs to classify the fracture or clinical outcome data accurately, such as range of motion, pain, or elbow function. We also were unable to identify the type of implants used to assess how internal fixation was achieved. Rather, our only clinical outcome was the need for reoperation. The need for operation can be misleading, as well. We assumed that most operations performed on the elbow in the 2 years after an elbow surgery are revision surgeries of the index operation, but we were not able to detect which subsequent surgeries in the elbow were indeed performed for revision purposes and which were for other reasons. There was also no identifier of laterality in our database, so it possible that a subsequent surgery was performed on the contralateral elbow or even that in addition to the radial head fracture, the concomitant injury identified was from the contralateral side. In addition, the database is not necessarily representative of the population. It is a private database and therefore lacks Medicare data in the older population as well as data from the indigent population. This could have affected the findings of the study because the population in the current study may skew younger than the general population of those sustaining radial head fractures, and the options for care may be different in this private payer population as well. An additional limitation is that the primary data r
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depend on physician coding with ICD-9 and CPT codes. Therefore, our results may have been affected by ambiguity inherent in coding, as well as possible miscoding or a lack of coding. One example is that patients with radial head and coronoid fractures may also have elbow dislocations that were not coded; similarly, those with radial head fractures and elbow dislocation may have coronoid fractures as well. As with any database study, results do not indicate causality, and cannot be used for patient care decisions. Nevertheless, nationwide data from PearlDiver reflects half a decade of practice patterns regarding the treatment of radial head fractures. These descriptive results may help provide preliminary data to motivate future clinical, epidemiological, or clinical effectiveness studies. Our hypothesis was that most isolated radial head fractures that require operative intervention are treated with ORIF as opposed to arthroplasty. We also hypothesized that as the injury becomes more complicated, such as a concurrent elbow dislocation or fracture, the rate of arthroplasty would increase. In addition, we expected that there would be more subsequent operations for fractures treated with arthroplasty as opposed to ORIF after 1 and 2 years. We found that the first 2 hypotheses were consistent with the results of our study but that ORIF was revised more frequently than radial head arthroplasty. Further investigation into practice variations and outcome is warranted.
8. Lindenhovius AL, Felsch Q, Doornberg JN, Ring D, Kloen P. Open reduction and internal fixation compared with excision for unstable displaced fractures of the radial head. J Hand Surg Am. 2007;32(5): 630e636. 9. VanBeek C, Levine W. Radial head—resect, fix, or replace. Oper Tech Orthop. 2010;20:2e10. 10. Ring D. Radial head fracture: open reduction-internal fixation or prosthetic replacement. J Shoulder Elbow Surg. 2011;20(2 suppl): S107eS112. 11. Sun H, Duan J, Li F. Comparison between radial head arthroplasty and open reduction and internal fixation in patients with radial head fractures (modified Mason type III and IV): a meta-analysis. Eur J Orthop Surg Traumatol. 2016;26(3):283e291. 12. Zwingmann J, Welzel M, Dovi-Akue D, Schmal H, Sudkamp NP, Strohm PC. Clinical results after different operative treatment methods of radial head and neck fractures: a systematic review and meta-analysis of clinical outcome. Injury. 2013;44(11):1540e1550. 13. Li N, Chen S. Open reduction and internal-fixation versus radial head replacement in treatment of Mason type III radial head fractures. Eur J Orthop Surg Traumatol. 2014;24(6):851e855. 14. Ruchelsman DE, Christoforou D, Jupiter JB. Fractures of the radial head and neck. J Bone Joint Surg Am. 2013;95(5):469e478. 15. Fowler JR, Goitz RJ. Radial head fractures: indications and outcomes for radial head arthroplasty. Orthop Clin North Am. 2013;44: 425e431. 16. Rineer CA, Guitton TG, Ring D. Radial head fractures: loss of cortical contact is associated with concomitant fracture or dislocation. J Shoulder Elbow Surg. 2010;19(1):21e25. 17. Mckee MD, Pugh DM, Wild LM, Schemitsch EH, King GJ. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures: surgical technique. J Bone Joint Surg Am. 2005;87(suppl 1 part 1):22e32. 18. Kodde IF, Kaas L, van Es N, Mulder PG, van Dijk CN, Eygendaal D. The effect of trauma and patient related factors on radial head fractures and associated injuries in 440 patients. BMC Musculoskelet Disord. 2015;16:135. 19. Antuña SA, Sánchez-Márquez JM, Barco R. Long-term results of radial head resection following isolated radial head fractures in patients younger than forty years old. J Bone Joint Surg Am. 2010;92(3):558e566. 20. Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Nyqvist F, Karlsson MK. Fractures of the radial head and neck treated with radial head excision. J Bone Joint Surg Am. 2004;86(9):1925e1930. 21. Watters TS, Garrigues GE, Ring D, Ruch DS. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Clin Orthop Relat Res. 2014;472(7): 2128e2135. 22. Levy JC, Formaini NT, Kurowicki J. Outcomes and radiographic findings of anatomic press-fit radial head arthroplasty. J Shoulder Elbow Surg. 2016:S1058eS2746. 23. Duckworth AD, Wickramasinghe NR, Clement ND, CourtBrown CM, McQueen MM. Radial head replacement for acute complex fractures: what are the rate and risks factors for revision or removal? Clin Orthop Relat Res. 2014;472(7):2136e2143. 24. Marsh JP, Grewal R, Faber KJ, Drosdowech DS, Athwal GS, King GJ. Radial head fractures treated with modular metallic radial head replacement: outcomes at a mean follow-up of eight years. J Bone Joint Surg Am. 2016;98(7):527e535.
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