Aims. To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically. Methods. A total of 209 children (mean age 6.84 years (SD 2.87)), who underwent surgical treatment for CMFs between March 2015 and March 2023 at six institutions, were retrospectively reviewed. Assessed risk factors included age, sex, laterality, dislocation direction and distance, preoperative proximal radial metaphysis width, time from injury to surgery, reduction method, annular ligament reconstruction, radiocapitellar joint fixation, ulnar osteotomy, site of ulnar osteotomy, preoperative and postoperative ulnar angulation, ulnar fixation method, progressive ulnar distraction, and postoperative cast immobilization. Independent-samples t-test, chi-squared test, and logistic regression analysis were used to identify the risk factors associated with unsuccessful RHR. Results. Redislocation occurred during surgery in 48 patients (23%), and during follow-up in 44 (21.1%). The mean follow-up of patients with successful RHR was 13.25 months (6 to 78). According to the univariable analysis, time from injury to surgery (p = 0.002) and preoperative dislocation distance (p = 0.042) were identified as potential risk factors for unsuccessful RHR. However, only time from injury to surgery (p = 0.007) was confirmed as a risk factor by logistic regression analysis. Receiver operating characteristic curve analysis and chi-squared test confirmed that a time from injury to surgery greater than 1.75 months increased the rate of unsuccessful RHR above the cutoff (p = 0.002). Conclusion. Time from injury to surgery is the primary independent risk factor for unsuccessful RHR in surgically treated children with CMFs, particularly in those with a time from injury to surgery of more than 1.75 months. No other factors were found to influence the incidence of unsuccessful RHR. Surgical reduction of paediatric CMFs should be performed within the first two months of injury whenever possible. Cite this article: Bone Jt Open 2024;5(7):581–591

Introduction. The action of the radial head in the stability of the elbow is currently admitted. Its conservation is not always possible in complex fractures. The association with a posterolateral dislocation of the elbow leads to a higher risk of instability of the elbow joint and also at a longer term to degenerative changes. Some authors recommend the use of metallic radial head implant, acting as a spacer. The results seems encouraging but should the resection arthroplasty associated with the repair of the medial collateral ligament be abandoned?. Material and methods. In an amount of 35 consecutive patients who were taken in charge for an elbow dislocation 26 were included in this retrospective study, 13 of them had the association of a dislocation and a fracture of the radial head. In all 13 cases the radial head was considered as inadequate with a conservative treatment and was resected. The patients were assessed clinically according to the American Shoulder and Elbow Surgeons score (ASES) and the Mayo elbow performance index with a mean follow-up of 13 years (ranging from 5 to 15). The degenerative changes were assessed on plan × rays and an additional axial view according to the 4 stages described by Morrey. Results. No redislocation occurred. According to the Broberg/Morrey index 92% of the patients were considered as having a good result. They returned to work with no hindering. Signs of osteoarthritis grade 1 or 2 were observed and were clinically well tolerated. There was no difference for this item between the patients who conserved their radial head and those who sustained a resection. All patients were satisfied although they were protecting their joint against overuse while working. Discussion. The studies about the use of prosthesis of the radial head offer similar functional results. Degenerative changes on the trochleo ulnar joint are identical in all type of treatment. In order to prevent stiffness in the elbow joint an early post operative rehabilitation is recommended, it justifies a surgical stabilization associated with the use of an adapted dynamic splint. Conclusion. In case of elbow dislocation with a fracture of the radial head when its preservation is impossible, the resection without any prosthetic replacement remains a reasonable option if associated with a repair of the medial collateral ligament. At long term the functional results are still good with mild signs of osteoarthritis eliminating ipso facto the problem of an implant survivorship

Background. Chronic acquired radial head dislocations pose a complex problem in terms of surgical decision making, especially if surgery has already previously failed. There are several underlying causes that should be investigated, including previous trauma resulting in a missed Monteggia fracture. Aim. To review the clinical and radiological outcomes for children up to 18 years of age, with a radial head dislocation treated with circular frame surgery. Method. A retrospective study was designed to identify patients from our departmental database who had undergone circular frame surgery to reduce the radial head during the past 6 years. Results. 20 patients were identified with a mean age of 11 years (3 – 17). Fourteen patients had a diagnosis of missed Monteggia fracture, three patients had Hereditary Multiple Exostoses, one had Nail Patella syndrome, one had Osteogenesis Imperfecta and one had rickets. The average delay between trauma and frame surgery was three years (0 – 7). All patients achieved union of their ulnar or radial osteotomy. The average frame duration was 167 days (61 – 325) and complications included delayed union and residual radial head subluxation. Thirteen patients achieved at least 40 degrees of supination, and 10 patients achieved at least 40 degrees of pronation. Eighteen patients achieved an arc of movement from full extension to at least 110 degrees of flexion. Eleven patients reported their pain level at final follow-up, of which 9 had no pain at all. Conclusion and Discussion. Circular frame surgery was a reliable and consistent method of reducing chronic radial head dislocations and improving function. Radiological appearances of mild residual subluxation of the radial head were clinically well tolerated and generally required no further treatment

A common location for radius fracture is the proximal radial head. With the arm in neutral position, the fracture usually happens in the anterolateral quadrant (Lacheta et al., 2019). If traditional surgeries are not enough to induce bone stabilization and vascularization, or the fracture can be defined grade III or grade IV (Mason classification), a radial head prosthesis can be the optimal compromise between bone saving and recovering the “terrible triad”. A commercially available design of radial head prosthesis such as Antea (Adler Ortho, Milan, Italy) is characterized by flexibility in selecting the best matching size for patients and induced osteointegration thanks to the Ti-Por. ®. radial stem realized by 3D printing with laser technique (Figure 1). As demonstrated, Ti-Por. ®. push-out resistance increased 45% between 8 −12 weeks after implantation, hence confirming the ideal bone-osteointegration. Additional features of Antea are: bipolarity, modularity, TiN coating, radiolucency, hypoallergenic, 10° self-aligning. The osteointegration is of paramount importance for radius, in fact the literature is unfortunately reporting several clinical cases for which the fracture of the prosthesis happened after bone-resorption. Even if related to an uncommon activity, the combination of mechanical resistance provided by the prosthesis and the stabilization due to the osteointegration should cover also accidental movements. Based upon Lacheta et al. (2019), after axial compression-load until radii failure, all native specimens survived a compression-load of 500N, while the failure happened for a mean compression force of 2560N. The aim of this research study was to test the mechanical resistance of a radial head prosthesis obtained by 3D printing. In detail, a finite element analysis (FEA) was used to understand the mechanical resistance of the core of the prosthesis and the potential bone fracture induced in the radius with simulated bone- resorption (Figure 2a). The critical level was estimated at the height for which the thickness of the core is the minimum (Figure 2b). Considered boundary conditions:. - Full-length prosthesis plus radius out of the cement block equal to 60mm (Figure 2a);. - Bone inside the cement equal to 60mm (Figure 2b);. - Load inclined 10° epiphysiary component (Figure 2c);. - Radius with physiological or osteoporotic bone conditions;. - Load (concentrated in the sphere simulating full transmission from the articulation) of 500N or 1300N or 2560N. Figure 3 shows the results in terms of maximum stress on the core of the prosthesis and the risk of fracture (Schileo et al., 2008). According to the obtained results, the radial head prosthesis shows promising mechanical resistance despite of the simulated bone-resorption for all applied loads except for 2560N. The estimated mechanical limit for the material in use is 200MPa. The risk of fracture is in agreement with the experimental findings (Lacheta et al. (2019)), in fact bone starts to fail for the minimum reported failure load, but only for osteoporotic conditions. The presented FEA aimed at investigating the behavior of a femoral head prostheses made by 3D printing with simulated bone-resorption. The prosthesis shows to be a skilled solution even during accidental loads. For any figures or tables, please contact the authors directly

Where reconstruction is deemed impossible, excision of the radial head has been the mainstay of treatment for shattered radial head and neck fractures. While some patients seem to do well after the procedure, some develop progressive instability and pain because of proximal translocation of the radius. We looked at a new procedure in which a metal radial head is inserted to provide greater stability after the excision. Historically silicone prostheses have been used, but these were found to fail dramatically after a time. We recruited 11 patients requiring radial head replacements. Their ages ranged from 26 to 54 years. In five patients the dominant arm was affected. The radial head was deemed non-reconstructable in all patients, and the alternative method of treatment would have been radial head excision. In one patient, radial head replacement was performed 14 years after previous radial head excision. A standardised procedure was performed, replacing the radial head with an Evolve modular radial head prosthesis. At follow-up, we assessed patient satisfaction, range of movement, overall stability of the prostheses, grip strength and return to full activity. The postoperative range of movement was assessed at three and six weeks, and the outcome in terms of mobility at six months. Supination ranged between 40( and 90( and pronation between 40( and 85(. Elbow extension ranged between -5( and -30 and flexion between 100( and 150(. We concede that the follow-up period has been short, but early results suggest that radial head replacement may be a good option in patients in whom radial head reconstruction is not possible

Radial head fractures are relatively common, representing approximately one-third of all elbow fractures. Outcomes are generally inversely proportional to the amount of force involved in the mechanism of injury, with simple fractures doing better than more comminuted ones. However, the prognosis for these fractures may also be influenced by associated injuries and patient-related factors (age, body index mass, gender, tobacco habit, etc.) The purpose of this study is to evaluate which factors will affect range of motion and function in partial radial head fractures. The hypothesis is that conservative treatment yields better outcomes. This retrospective comparative cohort study included 43 adult volunteers with partial radial head fracture, a minimum one-year follow up, separated into a surgical and non-surgical group. Risk factors were: associated injury, heterotopic ossification, worker's compensation, and proximal radio-ulnar joint implication. Outcomes included radiographic range of motion measurement, demographic data, and quality of life questionnaires (PREE, Q-DASH, MEPS). Mean follow up was 3.5 years (1–7 years). Thirty patients (70%) had associated injuries with decreased elbow extension (−11°, p=0.004) and total range of motion (−14°, p=0.002) compared to the other group. Heterotopic ossification was associated with decreased elbow flexion (−9°, p=0.001) and fractures involved the proximal radio-ulnar joint in 88% of patients. Only worker's compensation was associated with worse scores. There was no difference in terms of function and outcome between patients treated nonsurgically or surgically. We found that associated injuries, worker's compensation and the presence of heterotopic ossification were the only factors correlated with a worse prognosis in this cohort of patients. Given these results, the authors reiterate the importance of being vigilant to associated injuries

Purpose. There have been a number of described techniques for sizing the diameter of radial head implants. All of these techniques, however, are dependent on measurements of the excised native radial head. When accurate sizing is not possible due to extensive comminution or due to a previous radial head excision, it has been postulated that the proximal radioulnar joint (PRUJ) may be used as an intraoperative landmark for correct sizing. The purpose of this study was to: 1) determine if the PRUJ could be used as a reliable landmark for radial head implant diameter sizing when the native radial head in unavailable, and (2) determine the reliability of measurements of the excised radial head. Method. Twenty-seven fresh-frozen denuded ulnae and their corresponding radial heads (18 males, 9 females) were examined. The maximum diameter (MaxD), minimum diameter (MinD) and dish diameter (DD) of the radial heads were measured twice, 3–5 weeks apart, using digital calipers. Two fellowship-trained upper extremity surgeons, an upper extremity fellow and a senior orthopedic resident were then asked to independently select a radial head implant diameter based on the congruency of the radius of curvature of the PRUJ to that of the radial head trial implants. The examiners were blinded to the native radial head dimensions. This selection was repeated 3–5 weeks later by two of the investigators. Correlation between radial head measurements and radial head implant diameter sizes was assessed using Pearsons correlation coefficient (PCC) and inter and intra-observer reliability were assessed using intra-class correlation coefficient (ICC). Results. There was a positive correlation between each of the radial head measurements (MaxD, MinD and DD) and the selected radial head implant diameters (PCC of 0.56, 0.59 and 0.51 respectively; p<0.01). Measuring the MaxD, MinD and DD of the radial head showed excellent inter-observer reliability (ICC of 0.99, 1.00 and 0.82 respectively) and excellent intra-observer reliability (ICC of 0.99, 0.98 and 0.75 respectively). The PRUJ sizing method used to determine the diameter of the radial head implant showed poor inter-observer reliability with an ICC of 0.34 but good intra-observer reliability (ICC = 0.76). Conclusion. Measurements of the diameter of the excised radial head showed excellent intra and inter-observer reliability suggesting that the excised radial head, when available, should be used to select the radial head implant diameter. The inter-observer reliability of using the PRUJ for sizing the diameter of radial head implants was poor, indicating that this method is an unreliable technique for radial head implant diameter sizing. However, the high intra-observer reliability of the PRUJ method indicates that an observer tends to make the same size estimation, even weeks apart. This study suggests that the PRUJ radius of curvature may be different than that of the radial head. Further studies are needed to verify this hypothesis

Radial head fractures are common and mainly require a functional conservative treatment. About 20% of patients will present an unsatisfactory final functional result. There is, however, little data allowing us to predict which patients are at risk of bad evolve. This makes it difficult to optimize our therapeutic strategies in these patients. The aim of this study is to determine the personal and environmental factors that influence the functional prognosis of patients with a radial head fracture. We realized over a 1-year period a prospective observational longitudinal cohort study including 125 consecutive patients referred for a fracture of the radial head in a tertiary trauma center. We originally collected the factors believed to be prognostic indicators: age, sex, socioeconomic status, factors related to trauma or fracture, alcohol, tobacco, detection of depression scale, and financial compensation. A clinical and radiological follow-up took place at 6 weeks, 3 months, 6 months, and 1 year. The main functional measurement tool is the Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand (DASH). 123 patients were included in the study. 114 patients required nonsurgical management. 102 patients completed the 1-year follow-up for the main outcome (89 for the DASH score). Two patients required an unplanned surgery and were excluded from analyses. At 1 year, the average MEPS was 96.5 (range, 65–100) and 81% of subjects had an excellent result (MEPS ≥90). The most constant factor to predict an unsatisfactory functional outcome (MEPS <90 or DASH >17) is the presence of depressive symptoms at the initial time of the study (P = 0.03 and P = 0.0009, respectively). This factor is present throughout the follow-up. Other observed factors include a higher socioeconomic status (P = 0.009), the presence of financial compensation (P = 0.027), and a high-velocity trauma (P = 0.04). The severity of the fracture, advanced age, female sex, and the nature of the treatment does not influence the result at 1 year. No factor has been associated with a reduction in range of motion. Most of the radial head fractures heal successfully. We identified for the first time, with a valid tool, the presence of depressive symptoms at the time of the fracture as a significant factor for an unsatisfactory functional result. Early detection is simple and fast and would allow patients at risk to adopt complementary strategies to optimize the result

Fracture or resection of the radial head can cause unbalance and long-term functional complications in the elbow. Studies have shown that a radial head excision can change elbow kinematics and decrease elbow stability. The radial head is also important in both valgus and varus laxity and displacement. However, the effect of radial head on ulnohumeral joint load is not known. The objective of this experimental study was to compare the axial loading produced at the ulnohumeral joint during active flexion with and without a radial head resection. Ten cadaveric arms were used. Each specimen was prepared and secured in an elbow motion simulator. To simulate active flexion, the tendons of the biceps, brachialis, brachioradialis, and triceps were attached to servo motors. The elbow was moved through a full range of flexion. To quantify loads at the ulnohumeral joint, a load cell was implanted in the proximal ulna. Testing was conducted in the intact then radial head resected case, in supination in the horizontal, vertical, varus and valgus positions. When comparing the average loads during flexion, the axial ulnar load in the horizontal position was 89±29N in an intact state compared to 122±46N during radial head resection. In the vertical position, the intact state produced a 67±16N load while the resected state was 78±23N. In the varus and valgus positions, intact state resulted in loads of 57±26N and 18±3N, respectively. Conversely, with a radial head resection, varus and valus positions measured 56±23N and 54±23N loads, respectively. For both joint configurations, statistical differences were observed for all flexion angles in all arm positions during active flexion (p=0.0001). When comparing arm positions and flexion angle, statistical differences were measured between valgus, horizontal and vertical (p<0.005) except for varus position (p=0.64). Active flexion caused a variation in loads throughout flexion when comparing intact versus radial head resection. The most significant variation in ulnar loading occurred during valgus and horizontal flexion. The vertical and varus position showed little variation because the position of the arm is not affected by the loss of the radial head. However, in valgus position, the resected radial head creates a void in the joint space and, with gravity, causes greater compensatory ulnar loading. In the horizontal position, the forearm is not directly affected by gravitational pull and cannot adjust to counterbalance the resected radial head, therefore loads are localised in the ulnohumeral joint. These findings prove the importance of the radial head and that a radial head resection can overload the ulnohumeral side

INTRODUCTION:. Radial head arthroplasty is a reliable procedure with good functional outcomes when faced with irreparable radial head fractures. Since the first attempt at arthroplasty by Speed in 1941, there have been a variety of different designs created for radial head prostheses. There has been considerable recent interest in bipolar radial head components. However, to date, there have been few biomechanical studies comparing bipolar components to their monopolar counterparts. We examine the effects of alteration of axial length of the radial head prosthesis and force conveyed at the radiocapitellar joint in a head-to-head comparison of bipolar implants to monopolar implants. METHODS:. Sixteen fresh-frozen, sided cadaveric arms were utilized. Radial heads were resected and either a monopolar, rigid, metal radial head prosthesis (Solar, Stryker, Mahwah, NJ) was implanted or a bipolar metal prosthesis used (Katalyst, Integra, Plainsboro, NJ). Adjustments of radial head length were made in 2 mm increments using radiolucent washers to create an understuffed (−2), neutral (0), and overstuffed (+2, +4) effect, see Fig. 1. Forearms were cyclically loaded in compression from 13N to 130N with the forearm in neutral. Radiocapitellar forces were measured using Tekscan (Tekscan, Inc., Boston, MA) pressure sensors with radial head length set at −2 mm, 0, +2 mm and +4 mm and comparisons were made with the neutral (0) radial head, see Fig. 2. Multivariant ANOVA with Tukey's HSD correction was used for statistical analysis. RESULTS:. Radiocapitellar average peak pressures using monopolar and bipolar radial heads in arms that were understuffed (−2 mm), were 0.54 and 0.39 MPa, respectively; neutral (0 mm), 0.68 and 0.36 MPa; and overstuffed (+2 mm), 0.44 and 0.39 MPa; (+4 mm), 0.48 and 0.40 MPa, respectively. There was a noticeable stepwise increase in force transmitted with progressive radial head lengthening regardless of implant design. Radiocapitellar forces were almost 1.5 times greater with monopolar radial head overstuffing (+4) compared to neutral (0) while they essentially doubled with bipolar radial head overstuffing (+4) compared to neutral (0) (p < 0.01). The average change in measured values for the monopolar prostheses compared to the bipolar prostheses in the same arm are shown in Figure 2. DISCUSSION:. Progressive radial head lengthening regardless of implant design was associated with a stepwise increase in radiocapitellar joint force. Radiocapitellar forces where notably lower with the bipolar radial head when compared to their monopolar counterparts. This may in part be due to the bipolar design which allows for increased play at the radiocapitellar junction., see Fig. 3. Significance: Sizing and selection of the radial head implant plays a critical role in restoring native radiocapitellar loads and may prevent accelerated wear at the radiocapitellar joint after radial head arthroplasty. Figure 1 – Radial head length was controlled by applying 2 mm thick washers beneath the head, shown here with a monopolar prosthesis. Figure 2 – The bipolar radial head transmitted less force, greater contact area and lower peak pressures than with monopolar prostheses. Figure 3 – This radiographic image shows the potential for the bipolar radial head implant to realign to the joint under load

This novel modification of the posterior approach allows a low hazard exposure and easier surgery to the radial head. Methods and Materials: The most commonly used approaches are from the lateral aspect. The limitations of this approach in particular for radial head replacement is that it is a tight exposure, there is a risk of damage to the posterior interosseous nerve and there is always a difficulty in dislocation due to the presence of the interosseous membrane. The posterolateral approach to the proximal radius and ulna was described by Boyd, Gordon and Thompson. This approach avoids damage to the posterior interosseous nerve but the annular ligament requires incision and repair. Approach: Position the forearm in pronation aligning the ulnar styloid with lateral epicondyle of the humerus. A tencentimetre long incision is then made on the lateral border of the ulna exposing deep fascia. Following this a 1cm flap of fascia is left on the ulna and anconeus is lifted off the bone. This exposes underlying radial head, annular ligament and interosseous membrane. After identifying the ulnar insertion of annular ligament a 0.5 cm bone is osteotomised with annular ligament attached from the supinator tuberosity. The radial head osteotomy is performed with the radial head in pronation to align it with shaft of radius using specially designed jig. Osteotomy of the radial head has to be at right angles to the axis of the forearm. This is a line between centre of the radial neck to the ulnar styloid process. Radial head can now be subluxed out of the wound and preparing for a replacement. The trial prosthetic radial head is then inserted and reduced. The bone fragment with annular ligament attachment is then reduced back into the original slot. This allows one to judge the size of prosthetic radial head if ligament is too tight a small diameter implant is required. The bone fragment is reattached using especially devised washer with, wire holes and a 2mm AO screw. Results: This approach is easier, safer and reproducible. When compared to lateral approach it provides an easier access and excellent stability in radial head replacement. We recommend this approach for radial head replacements and difficult trauma cases

A primary mode of failure for total elbow arthroplasty is osteolysis caused by wear debris. Loading of the polyethylene components by off-axis bearing loads is the likely cause of this debris. Load transfer at the elbow is affected by many factors, including the state of the radial head. New implant designs provide the option to use the intact, resected, or implant reconstructed radial head. However, the effect of the radial head state on stability and loading has not yet been investigated in these new implant designs. We postulated that the presence of the native or prosthetic radial head would reduce the wear-inducing loading patterns experienced by the humeral component and improve joint stability compared to when the radial head is resected. Seven cadaveric upper extremities, amputated at the mid humerus, were tested in a joint motion simulator equipped with an electromagnetic tracking system to quantify motion. Simulated active flexion was tested with the arm in the dependent position. Passive elbow flexion was conducted with the arm in the varus and valgus gravity-loaded orientations. After testing the intact elbow, the collateral ligaments were sectioned and a linked Latitude ulno-humeral joint replacement was performed (Tornier, Stafford, TX). The humeral component was instrumented with strain gauges for measuring varus-valgus bending and internal-external torsion. Ulno-humeral kinematics and humeral component loading were measured when the radial head was intact, resected, and following radial head arthroplasty. An increase in varus-valgus laxity was noted following replacement of the ulno-humeral joint with the prosthesis (p< 0.05). There was no difference in joint laxity between the intact radial head, radial head excision or radial head arthroplasty (p> 0.05). Torsion moments increased, while bending loads decreased in the humeral component following radial head excision and were restored following radial head arthroplasty (p< 0.05). No significant effect of radial head state on varus-valgus joint laxity was observed for the linked ulno-humeral prosthesis. In the absence of collateral ligaments, the observed post-operative increase in varus-valgus laxity can be attributed to the difference in laxity between the native joint and the articular components of the linked implant. Load transfer was altered by radial head excision, which may affect the magnitude of bearing wear and the incidence of aseptic loosening. Further studies are required to determine whether these changes in load transfer influence wear of the polyethylene components or implant loosening

Aim of the study: To define the dimensions of the radial head, as well as the radiocapitellar and proximal radio-ulnar joints. The most congruent portions of the radial head articulations were determined. Materials & Methods: Computed tomography scans of twenty-two cadaveric adult elbows were obtained in three forearm positions – supination, neutral, pronation. The radial head dimensions, the radiocapitellar joints, and the proximal radioulnar joints were also measured. Multivariate analysis of variance was used to determine which portions of each articulation were the most congruent. Results: At the level of the radial trough, the maximum diameter was 22.3 mm, the minimum diameter was 20.9 mm, and the diameter difference was 1.4 mm. This difference represented only 6.3% of the overall maximum diameter. The depth of curvature of the radial head trough was 2.3 mm, the radial head length was 9.8 mm, and the radial neck length was 10.7 mm. At the isthmus of medullary canal, the maximum diameter was 9.7 mm, the minimum diameter was 8.2 mm, and the diameter difference was 1.5 mm. This difference represented 15.6% of the maximum diameter. The average radiocapitellar distance at the radial lip was 4.0 mm, the trough 2.4 mm, and the ulnar lip 2.2 mm. Thus, the radial head tended to become uncovered at the radial lip (p < 0.0001). The radiocapitellar joint was tighter in pronation than in supination (p = 0.0008). The proximal radioulnar joint was most congruent at the MPRUJ (middle proximal radioulnar joint), at the midportion and posterior aspects, rather than the anterior aspect (p < 0.0001). The PRUJ coverage was between 69.0 and 79.2 degrees. Conclusions: Prosthesis trial sizing should be judged by the articulations providing the most congruency –. 1) the ulnar lip or trough of the radiocapitellar joint in pronation and. 2) the posterior or midportion of the MRPUJ

The aim of this study was to report the outcome of radial head replacement for complex fractures of the radial head, and determine any risk factors for prosthesis removal or revision. We identified 119 patients who were managed acutely using primary radial head replacement for an unstable fracture of the radial head over a 15-year period. Demographic data, fracture classification, management, complications and subsequent surgeries were recorded following retrospective clinical record review. There were 105 (88%) patients with a mean age of 50 yrs (16–93) and 54% (n=57) were female. There were 95 (91%) radial head fractures and 96% were a Mason type 3 or 4 injury. There were 98 associated injuries in 70 patients (67%), with an associated coronoid fracture (n=29, 28%) most frequent. All implants were uncemented monopolar prostheses, with 86% metallic and 14% silastic. At a mean short-term follow-up of 1 year (range, 0.1–5.5; n=87) the mean Broberg and Morrey score was 80 (range, 40–99), with 49.5% achieving an excellent or good outcome. At a final mean review of 6.7 yrs (1.8–17.8), 29 (27%) patients had undergone revision (n=3) or removal (n=26) of the prosthesis. Independent risk factors of prosthesis removal or revision were silastic implant type (p=0.010) and younger age (p=0.015). This is the largest series in the literature documenting the outcome following radial head replacement for complex fractures of the radial head. We have demonstrated a high rate of removal or revision for all implants, with younger patients and silastic implants independent risk factors

Introduction. This study investigates the epidemiology of proximal radial fractures and potential links to social deprivation. Patients and Methods. From a prospective database we identified and analysed all patients who had sustained a fracture of the radial head or neck over a one year period. The degree of social deprivation was assessed using the Carstairs and Morris index. The relationship between demographic data, fracture characteristics and deprivation categories was determined using statistical analysis. Results. Two hundred and ninety radial head (n=203) and neck (n=87) fractures were diagnosed with a mean age of 44.3years (13–94). There was no significant difference with regards age or gender predominance when comparing radial head and neck fractures directly. The mean age of males was significantly younger when compared to females for radial head (p<0.001) and neck (p<0.001) fractures, but with no gender predominance seen. Associated injuries (n=25) were related to increasing age (p=0.006), radial head fractures (p=0.003) and increasing fracture complexity according to the Mason classification (p<0.001). Social deprivation was related to the mean age at the time of fracture and the mechanism of injury (p<0.05 for both). Conclusions. Proximal radial fractures are frequently fragility fractures affecting older females and assessment for osteoporosis is recommended. Complex radial head fractures require thorough investigation for the presence of associated injuries

Introduction. Acquired chronic radial head (RH) dislocations present a significant surgical challenge. Co-existing deformity, length discrepancy and RH dysplasia, in multiply operated patients often preclude acute correction. This study reports the clinical and radiological outcomes in children, treated with circular frames for gradual RH reduction. Materials and Methods. Patient cohort from a prospective database was reviewed to identity all circular frames for RH dislocations between 2000–2021. Patient demographics, clinical range and radiographic parameters were recorded. Results. From a cohort of 127 UL frames, 30 chronic RH dislocations (14 anterior, 16 posterior) were identified. Mean age at surgery was 10yrs (5–17). Six pathologies were reported (14 post-traumatic, 11 HME, 2 Nail-Patella, 1 Olliers, OI, Rickets). 70% had a congruent RH reduction at final follow-up. Three cases re-dislocated and 6 had some mild persistent incongruency. Average follow up duration was 4.1yrs (9mnths-11.5yrs). Mean radiographic correction achieved in coronal plane 9. o. , sagittal plane 7. o. and carrying angle 12. o. Mean ulna length gained was 7mm and final ulnar variance was 7mm negative (congenital). All cases achieved bony union with 2 requiring bone grafting. Mean frame duration was 166 days. Mean final range of motion was 64. o. supination, 54 . o. pronation, 2. o. to 138. o. flexion. 5 complications and 7 further operations were reported. Conclusions. The majority of children having frame correction achieve complete correction or minor subluxation, which is well tolerated clinically. Frame assisted reduction is an effective tool for selective complex cases irrespective of the pathology driving the RH dislocation

Background. The traditional Kocher approach for lateral elbow exposure is often complicated by injury to the posterior interosseous nerve (PIN) and the lateral ulnar collateral ligamentous (LUCL). Kaplan approach is less commonly used, due to its known proximity to the PIN. Extensor Digitorum Communis (EDC) splitting approach allows possible wide surgical exposure and low risk of LUCL damage. The comparison of PIN injury during surgical dissection among these 3 common lateral approaches was not previously evaluated. We aim to determine the anatomical proximity of the PIN in these 3 common lateral elbow approaches and to define a safe zone of dissection for the surgical exposure. Methods. Cadaveric dissections of 9 pairs of fresh frozen adult upper extremities were performed using EDC splitting, Kaplan and Kocher approach to the radial head sequentially in a randomised order. The radial head and PIN were exposed. A mark was made on the radial head upon the initial exposure during dissection. Measurements from the marked point of the radial head to the PIN were made. Study has been approved by the ethics committee. Results. The EDC splitting approach is associated with a significantly lower chance of encountering the PIN along the entry of dissection to reach the radial head as compared to the Kaplan approach. The Kocher approach has a lower chance of encountering the PIN along the entry of dissection to reach the radial head as compared to both Kaplan and EDC splitting approach. Conclusions. The EDC splitting approach provides adequate exposure without injury to the lateral ligamentous complex nor need to elevate or retract the EDC and ECU muscle mass that could risk injuring the PIN. The Kaplan approach should be done by experienced surgeons who are familiar with the anatomy in this region, with extreme caution due to proximity of the point of entry to the PIN. Level of evidence. IV

To study the surgical outcome of multi-fragmentary, un-reconstructable radial head fractures managed acutely by a radial head prosthetic replacement, we retrospectively reviewed nineteen radial head fractures that were treated acutely with a radial head replacement, over a four-year period in three district general hospitals. Nineteen patients were clinically and radiologically assessed for this study. Functional assessment was performed with the Mayo elbow performance score (MEPS). No patient achieved full functional range of motion. The average range of flexion was 110° (range 80° to 120°), average extension deficit of 35° (range 30° to 45°), average pronation was 35° (range 0° to 65°), and average supination was 50° (range 30° to 85°). Complications included implant removal due to loosening (n=1), elbow stiffness (n=2), and instability (n=1), the latter case requiring a revision of the radial head prosthesis. Some degree of persistent discomfort was noticed in all cases. Five patients were tolerant of the final functional outcome. The average Mayo elbow score was 68/100 (range 55 to 80). One patient had an intra-operative fracture of the radial metaphysis during insertion of the implant. Conclusions. Radial head replacement in general orthopaedic, low volume practice failed to achieve satisfactory results. Contrary to popular belief, it is a technically demanding operation, for which surveillance should be continued for a minimum of one year. Strict indications for prosthetic replacement should be followed and implant selection has yet to be proven to make a significant positive contribution. Our review highlights the need for a stricter adherence to indications; surgery should not be under-estimated and devolved to trainees, and our understanding of the radial axis of the elbow and forearm remains relatively rudimentary

In Essex-Lopresti injuries, the prevailing concept, according to which the stability of the forearm can be restored after fixation of the fracture or replacement of the radial head by a metallic implant, is disputable. The aim of this study is to evaluate the midterm results in 12 patients with an Essex-Lopresti injury who were treated operatively. We studied 12 patients, with comminuted fracture of the radial head, either isolated (4 patients) or with injury of the ipsilateral (4 patients) or the contralateral (4 patients) arm. Initially, 10 patients were treated with excision of the radial head whereas 2 underwent internal fixation of the radial head and pinning of the DRUJ. Eventually, everyone developed a subluxation of DRUJ and had to be treated for an established Essex-Lopresti injury, 1–7 months after the initial injury. Six patients were treated with equalization of the radioulnar length (ulnar shortening osteotomy with or without a distractor-external fixator) and restoration of the TFC, while six patients underwent replacement of the radial head with a titanium implant, equalization of the radioulnar length and restoration of the TFC. The results were evaluated after a mean follow-up of 4 years (1–12 years), based on radiological and clinical criteria. The six patients in whom the titanium radial head implant was used presented with good results, even though two of them reported forearm pain during activity. On the contrary, in the rest of the patients the radioulnar incongruity reappeared in varying degrees. However the poor radiological result was not consistent to the clinical one. We conclude that in cases of complete rupture of the interosseous membrane, internal fixation or replacement of the radial head with a metallic implant will not probably provide us with a good long-term functional result

Background. Radial head fractures are the commonest fractures involving the elbow. The goals of treatment are to restore stability, preserve motion, and maintain the relative length of the radius. Fortunately, most simple uncomplicated fractures can be treated non-operatively. Choosing between fixation and radial head replacement for comminuted fractures remains difficult. Excision of radial head fractures is not an ideal option in unstable elbow injuries. The purpose of this systematic review was to search for and critically appraise articles directly comparing functional outcomes and complications for fixation (open reduction internal fixation, ORIF) versus arthroplasty for comminuted radial head fractures (Mason type 3) in adults. Method. A comprehensive search of Medline, Embase and Cochrane databases using specific search terms and limits was conducted. Strict eligibility criteria were applied to stringently screen resultant articles. Three comparative studies were identified and reviewed. Results. Three comparative studies were identified and reviewed: two studies found significantly better Broberg & Morrey functional scores after replacement compared with ORIF in Mason type 3 fractures. The third study found no significant differences in Mayo functional score or range of motion, but did find that grip strength was better after ORIF. Complication rates were too heterogenous for conclusion. Conclusion. Fixation with good reduction may be attempted in unstable Mason type 3 fractures, and arthroplasty may be considered if this is not possible. Further randomised comparative trials are required to clarify the decision-making between fixation and replacement. Functional outcomes and complications were conflicting in the studies included here. Ideally, treatment decision should take into account elbow stability and degree of comminution