Aims

In patients with a failed radial head arthroplasty (RHA), simple removal of the implant is an option. However, there is little information in the literature about the outcome of this procedure. The aim of this study was to review the mid-term clinical and radiological results, and the rate of complications and removal of the implant, in patients whose initial RHA was undertaken acutely for trauma involving the elbow.

Aims

The aim of this study was to evaluate the outcome of complex radial head fractures at mid-term follow-up, and determine whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA) should be recommended for surgical treatment.

Aims

Acute and chronic injuries of the interosseus membrane can result in longitudinal instability of the forearm. Reconstruction of the central band of the interosseus membrane can help to restore biomechanical stability. Different methods have been used to reconstruct the central band, including tendon grafts, bone-ligament-bone grafts, and synthetic grafts. This Idea, Development, Exploration, Assessment, and Long-term (IDEAL) phase 1 study aims to review the clinical results of reconstruction using a synthetic braided cross-linked graft secured at either end with an Endobutton to restore the force balance between the bones of the forearm.

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The aim of this study was to analyze how proximal radial neck resorption (PRNR) starts and progresses radiologically in two types of press-fit radial head arthroplasties (RHAs), and to investigate its clinical relevance.

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It has been hypothesized that proximal radial neck resorption (PRNR) following press-fit radial head arthroplasty (RHA) is due to stress-shielding. We compared two different press-fit stems by means of radiographs to investigate whether the shape and size of the stems are correlated with the degree of PRNR.

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

Essex-Lopresti injuries are often unrecognized acutely with resulting debilitating adverse effects. Persistent axial forearm instability may affect load transmission at both the elbow and wrist, resulting in significant pain. In the setting of both acute and chronic injuries metallic radial head arthroplasty has been advocated, however there is little information regarding their outcome. The purpose of this study was to assess the efficacy of a radial head arthroplasty to address both acute and chronic Essex-Lopresti type injuries. A retrospective review from 2006 to 2016 identified 11 Essex-Lopresti type injuries at a mean follow-up of 18 months. Five were diagnosed and treated acutely at a mean of 11 days (range, 8 to 19 days) from injury, while 6 were treated in a delayed fashion at a mean of 1.9 years (range, 2.7 months to 6.2 years) from injury with a mean 1.5 (range, 0 to 4) prior procedures. The cohort included 10 males with a mean age was 44.5 years (range, 28 to 71 years). A smooth stem, modular radial head arthroplasty was used in all cases. Outcomes included range of motion and radiographic findings such as ulnar variance, capitellar erosion, implant positioning and implant lucency using a modification of the method described by Gruen. Reoperations, including the need for ulnar shortening osteotomy, were also recorded. Three patients in each group (55%) reported persistent wrist pain. The mean ulnar variance improved from +5 mm (range, 1.8 to 7 mm) to +3.7 mm (range, 1 to 6.3 mm) at the time of final follow-up or prior to reoperation. Three (50%) patients in the chronic group underwent a staged ulnar shortening osteotomy (USO) to correct residual ulnar positive variance and to manage residual wrist pain. There were no reoperations in the acute group. Following USO, the ulnar variance in those three cases improved further to +3.5, +2.1, and −1.1 mm. No radial head prostheses required removal. Capitellar erosion was noted in five (45%) elbows, and was rated severe in one, moderate in two, and mild in two. Lucency about the radial head prosthesis stem was noted in eight (73%) cases, and rated as severe in 2 (18%), based on Gruen zones. Treatment of acute and chronic Essex-Lopresti lesions with radial head arthroplasty often results in persistent wrist pain. In the chronic setting, a planned USO was often necessary to restore axial forearm stability after radial head arthroplasty. Essex-Lopresti lesions represent a rare clinical entity that are difficult treat, particularly in the chronic setting. Early recognition and management with a smooth stem modular radial head arthroplasty may provide improved outcomes compared to chronic reconstruction

Aims

The aim of this study was to analyze the results of two radiocapitellar prostheses in a large case series followed prospectively, with medium-term follow-up.

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The crucial role of the radial head in the stability of the elbow in terrible triad injury is acknowledged. This retrospective study aims to compare the results of resection of a severely comminuted radial head with or without prosthetic arthroplasty as part of the reconstruction for this injury.

Aims. The aim of this retrospective multicentre study was to evaluate mid-term results of the operative treatment of Monteggia-like lesions and to determine the prognostic factors that influence the clinical and radiological outcome. Patients and Methods. A total of 46 patients (27 women and 19 men), with a mean age of 57.7 years (18 to 84) who had sustained a Monteggia-like lesion were followed up clinically and radiologically after surgical treatment. The Mayo Modified Wrist Score (MMWS), Mayo Elbow Performance Score (MEPS), Broberg and Morrey Score, and Disabilities of the Arm, Shoulder and Hand (DASH) score were used for evaluation at a mean of 65 months (27 to 111) postoperatively. All ulnar fractures were stabilized using a proximally contoured or precontoured locking compression plate. Mason type I fractures of the radial head were treated conservatively, type II fractures were treated with reconstruction, and type III fractures with arthroplasty. All Morrey type II and III fractures of the coronoid process was stabilized using lag screws. Results. Good results were found for the MMWS, with a mean of 88.4 (40 to 100). There were 29 excellent results (63%), nine good (20%), seven satisfactory (15%), and one poor (2%). Excellent results were obtained for the MEPS, with a mean of 90.7 (70 to 100): 31 excellent results (68%), 13 good (28%), and two fair (4%). Good results were also found for the functional rating index of Broberg and Morrey, with a mean score of 86.6 (57 to 100). There were 16 excellent results (35%), 22 good (48%), six fair (13%), and two poor (4%). The mean DASH score was 15.1 (0 to 55.8). Two patients had delayed wound healing; four patients had nonunion requiring bone grafting. One patient had asymptomatic loosening of the radial head prosthesis. Conclusion. Monteggia-like lesions are rare. With correct identification, classification, and understanding using CT scans followed by appropriate surgical treatment that addresses all components of the injury, good to excellent mid-term results can be achieved. Cite this article: Bone Joint J 2018;100-B:212–18

Aims

Radial head arthroplasty (RHA) may be used in the treatment of non-reconstructable radial head fractures. The aim of this study was to evaluate the mid-term clinical and radiographic results of RHA.

The clinical case refers to a male patient, 34 years old, admitted at the Emergency Department after a fall of 2 meters. Of that trauma, resulted an exposed Monteggia fracture type III – Gustillo & Anderson IIA – on his left arm. With this work, the authors intend to describe the evolution of the patient's clinical condition, as well as the surgical procedures he was submitted to. The authors used the patient's records from Hospital's archives, namely from the Emergency Department, Operating Room, Infirmary and Consultation, and also the diagnostic exams performed throughout the patient's clinical evolution. The clinical case began in December 2011, when the patient suffered a fall of 2 meters in his workplace. From the evaluation in the Emergency Department, it was concluded that the patient presented, at the left forearm, an exposed Monteggia type III fracture – Gustillo & Anderson IIA – combined with a comminuted fracture of the radial head. At the admission day, the wound site was thoroughly rinsed, the fracture was reduced and immobilized with an above-the-elbow cast, and antibiotics were initiated. Six days after admission, the patient was submitted to open reduction with internal fixation with plate and screws of the fracture of the ulna and radial head arthroplasty. The postoperative period was uneventful. Two months after the surgical procedure, inflammatory signals appeared with purulent secretion in the ulnar suture. Accordingly, the patient was submitted to fistulectomy, rinsing of the surgical site and a cycle of antibiotics with Vancomycin, directed to the S. aureus isolated from the purulent secretion. The clinical evolution was unfavorable, leading to the appearance of a metaphyseal pseudarthrosis or the ulna and dislocation of the radial head prosthesis. The previously implanted material was therefore removed, 4 months after the traumatic event; at the same time an external fixation device was applied and the first part of a Masquelet Technique was conducted. The second part of the aforementioned procedure was carried out in December 2012. The patient was discharged from the consultation after a 2 years follow-up, with a range of motion of the left elbow acceptable for his daily living activities. In spite of the multiple surgical rinsing procedures and directed antibiotics, the development of a metaphyseal pseudarthrosis of the ulna was inevitable. This clinical case illustrates how the Masquelet Technique presents itself as a good solution for the cases of non-union of fractures in the context of infection

This study compares the outcomes of two methods of fixation of displaced fractures of the radial neck. The 58 patients with a mean age of 38.5 years (18 to 56), were treated in a non randomised study with screws (n = 29) or a plate and screws (n = 29) according to the surgeon’s preference.

The patients were reviewed at one year. Radiographs and functional evaluations were carried out up to one year post-operatively, using the Broberg and Morrey functional evaluation score, range of movement, and assessment of complications.

The mean functional scores did not differ significantly between groups (90 (55 to 100) vs 84; 50 to 100, p = 0.09), but the mean range of forearm rotation in screw group was significantly better than in the plate group (152°; 110° to 170° vs 134°; 80° to 170°, p = 0.001). Although not statistically significant, the screw group had a lower incidence of heterotopic ossification than the plate group (n = 1) than the plated group (n = 3) and the pathology was graded as less severe.

Cite this article: Bone Joint J 2015;97-B:830–5

Unlinked, linked and convertible total elbow arthroplasties (TEAs) are currently available. This study is the first to report the clinical results of the convertible Latitude TEA. This was a retrospective study of a consecutive cohort of 63 patients (69 primary TEAs) with a mean age of 60 years (23 to 87). Between 2006 and 2008 a total of 19 men and 50 women underwent surgery. The mean follow-up was 43 months (8 to 84). The range of movement, function and pain all improved six months post-operatively and either continued to improve slightly or reached a plateau thereafter. The complication rate is similar to that reported for other TEA systems. No loosening was seen. Remarkable is the disengagement of the radial head component in 13 TEAs (31%) with a radial head component implanted.

Implantation of both the linked and the unlinked versions of the Latitude TEA results in improvement of function and decreased pain, and shows high patient satisfaction at mid-term follow-up.

Cite this article: Bone Joint J 2015; 97-B:681–8.

The Essex-Lopresti injury (ELI) of the forearm is a rare and serious condition which is often overlooked, leading to a poor outcome.

The purpose of this retrospective case study was to establish whether early surgery can give good medium-term results.

From a group of 295 patients with a fracture of the radial head, 12 patients were diagnosed with ELI on MRI which confirmed injury to the interosseous membrane (IOM) and ligament (IOL). They were treated by reduction and temporary Kirschner (K)-wire stabilisation of the distal radioulnar joint (DRUJ). In addition, eight patients had a radial head replacement, and two a radial head reconstruction.

All patients were examined clinically and radiologically 59 months (25 to 90) after surgery when the mean Mayo Modified Wrist Score (MMWS) was 88.4 (78 to 94), the mean Mayo Elbow Performance Scores (MEPS) 86.7 (77 to 95) and the mean disabilities of arm, shoulder and hand (DASH) score 20.5 (16 to 31): all of these indicate a good outcome.

In case of a high index of suspicion for ELI in patients with a radial head fracture, we recommend the following: confirmation of IOM and IOL injury with an early MRI scan; early surgery with reduction and temporary K-wire stabilisation of the DRUJ; preservation of the radial head if at all possible or replacement if not, and functional bracing in supination. This will increase the prospect of a good result, and avoid the complications of a missed diagnosis and the difficulties of late treatment.

Cite this article: Bone Joint J 2014;96-B:1385–91.

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

Purpose. Assess and report the functional and post-operative outcomes of complex acute radial head fractures with elbow instability treated by arthroplasty using an uncemented modular anatomic prosthesis. Methods. Over a 3-year period (2007–2010), 21 patients (mean age 51.9 years) were treated primarily with modular radial head arthroplasty (mean follow up of 27.1 months). Data was collected retrospectively using clinical notes, operation documentation and prospectively using validated scoring systems namely the Oxford Elbow Index, Quick DASH and the Mayo Elbow Performance Score. Associated elbow fractures, ligamentous injury and short to mid term post-operative outcomes including radiographic assessment were recorded. Results. The mean Oxford Elbow Score was 34.80 (range 20–48). The mean Quick Dash score was 26.01 (range 0–68.2). The Mayo Performance score showed 6 scored excellent, 5 scored good, 3 scored fair and 2 scored poor. Regarding post-operative outcomes, 1 patient had a radial head dislocation, 1 patient had prosthesis removal for ongoing pain and 1 patient had a total elbow replacement due to associated proximal ulna fracture non-union. 11 patients had an associated ligamentous injury of which 6 had an associated coronoid fracture. Of note, 7 patient's radiographs showed early signs of implant loosening; this was mainly asymptomatic. Conclusions. With regard to complex radial head fractures with elbow instability, patient outcome measures showed good functionality and overall patient satisfaction despite radiographic evidence of loosening. Post-operative complication rates were low. These findings support the use of this radial head prosthesis in arthoplasty surgery for the treatment of complex acute radial head fractures with elbow instability

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred.

This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence.

Cite this article: Bone Joint J 2013;95-B:151–9.