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

Background. Comminuted radial head fractures are challenging to treat with open reduction and internal fixation. Complicating matters further, radial head fractures are often associated with other elbow fractures and soft tissue injuries. Radial head arthroplasty is a favorable technique for the treatment of radial head fractures. The purpose of this study was to evaluate the functional outcomes of radial head arthroplasty using Modular Pyrocarbon radial head prosthesis in patients with unreconstructible radial head fractures. Methods. This single surgeon, single centre study retrospectively reviewed the functional and radiological outcomes of 21 consecutive patients requiring radial head arthroplasty for unreconstructible radial head fractures between July 2003 and July 2009. Patients were at least one year post-op and completed a Short-Form 36 (SF-36) questionnaire, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and the Mayo Elbow Performance Index (MEPI). These patients were independently physically examined and their post-operative radiographs were independently reviewed. Results. 21 patients (9 males and 12 females) were reviewed at a minimum of 12 months follow-up. The mean DASH score was 10.8 (0-34.1), the mean SF-36 physical score was 76.9 (35-96), the mean SF-36 mental score was 83.8 (60-94), and their MEPI score was 86.4 (70-100). Patients maintained 90% of their grip strength in their injured arm when compared to their un-injured arm and had 17. o. of fixed flexion in the affected arm. Radiologically, 14 cases had some degree of post-traumatic osteoarthritis, 12 cases had evidence of heterotrophic ossification, 5 had some evidence of periprosthetic lucency and 3 of our cases were radiologically but not functionally ‘overstuffed’. Conclusion. Radial Head Arthroplasty with Pyrocarbon Radial Head Prosthesis is a safe and effective option when treating unreconstructable comminuted radial head fractures yielding good functional and radiological outcomes and remains the treatment option of choice at our institution

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

Background. Radial head arthroplasty (RHA) is a popular method of treatment for complex fractures of the radial head. The purpose of this study was to investigate patient outcomes and radiographic findings associated with a single anatomical monopolar press-fit radial head system commonly used for the treatment of radial head fractures. Methods. A retrospective review of prospectively collected data was performed for a consecutive series of patients treated with RHA between November 2007 and April 2014. Patients with a minimum of 12-month follow-up were included. Most recent radiographs were evaluated for loosening, stress shielding, and instability. Post-operative motion and outcomes were reported at most-recent follow-up. Results. At an average follow-up of 30 months, 7 of the 17 patients (41%) demonstrated radiographic loosening. Six of the 10 patients (60%) without loosening demonstrated stress shielding (average 6mm). Functional outcome scores included a mean ASES of 74, MEPS of 87, VAS Pain of 1, VAS Function of 8 and SANE of 79. Average flexion-extension arc was 13°–138°, and average pronation-supination was 77°–76° (Figure 1). Of the patients with radiographic loosening, 86% had undergone RHA with an associated ligamentous injury of the elbow. Satisfaction among patients was high, as no patient reported an unsatisfactory outcome. Conclusions. The use of an anatomic, press-fit monopolar RHA in the management of acute complex radial head fractures has yielded excellent clinical outcomes despite high rates of radiographic loosening and stress shielding. Press-fit RHA in the setting of ligamentous injury warrants further investigation due to a high rate of implant loosening observed

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

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

Purpose. Limited information is available regarding the functional outcomes of radial head fractures managed with open reduction and internal fixation (ORIF). The purpose of this study was to determine the functional outcomes of radial head fractures treated with ORIF. Method. Fifty-two patients, with a mean age of 4412 years, who were treated with radial head ORIF were evaluated at a mean of 4.42.4 years. Thirty were isolated radial head fractures (Group A), 13 (Group B) were associated with a complex fracture-dislocation (terrible triad variants), and 5 (Group C) were associated with a proximal ulnar fracture (Monteggia/trans-olecranon variants). Fourty-four were partial articular fractures and 8 were complete articular fractures. Outcomes were assessed with physical and radiographic examination, and validated self-reported questionnaires. Results. The average PREE score (Patient Rated Elbow Evaluation) for Groups A, B, and C were 7.613.1, 12.313.4, and 108.5, respectively. The average MEPI (Mayo Elbow Performance Score) for Groups A, B, and C were 8913, 8511, and 918, respectively. For Groups A, B, and C respectively, the prevalence of radiographic radiocapitellar arthritis was 30%, 46%, and 20%. The average flexion/extension arc for Groups A, B, and C were 7 to 132, 6 to 134, and 10 to 132 respectively. Secondary surgery was performed in 17% of cases, most commonly for decreased motion. Three comminuted fractures failed ORIF and required conversion to radial head arthroplasty. Conclusion. Patients with radial head fractures, including those associated with complex fracture-dislocations, can achieve excellent functional outcomes with low self reported pain and disability when treated with ORIF, despite radiographic evidence of mild post-traumatic arthritis