• Users Online: 221
  • Print this page
  • Email this page


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 43-47

Retrospective study to know the outcome of radial head replacement in acute fracture of radial head


1 Department of Trauma and Emergency (Orthopaedics), IGIMS, Patna, Bihar, India
2 Department of Orthopaedics, IGIMS, Patna, Bihar, India

Date of Submission17-Jan-2022
Date of Acceptance24-Jan-2022
Date of Web Publication12-Feb-2022

Correspondence Address:
Rakesh Kumar
Assistant Professor, Department of Trauma and Emergency (Orthopaedics), IGIMS, Raja Bajar, Seikhpura, Patna - 800 014, Bihar
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jigims.jigims_5_22

Rights and Permissions
  Abstract 


Background: Radial head arthroplasty is commonly used to treat acute unreconstructible radial head fractures. The purpose of this study was to report on the clinical and radiographic outcomes after radial head arthroplasty with a metallic implant for the treatment of acute radial head fractures.
Materials and Methods: Seven patients with unconstructable communited acute radial head fractures were treated with radial head replacement. Patients were selected according to the indication and rejected or delayed according to contraindication. Necessary written informed consent was taken.
Observation and Results: All patients had good alignment and the full range of the function of the elbow without any major complications. Radiological alignment was also comparable with the other side. Follow-up noted up to 6 months only.
Conclusions: Radial head replacement can be a good alternative for the treatment of communited radial head fractures which cannot be fixed. Although longer follow-up is needed.

Keywords: Acute radial head fracture, radial head replacement, smooth-stemmed metallic radial head implant


How to cite this article:
Shankar A, Kumar R, Kumar A, Kumar R, Kumar S. Retrospective study to know the outcome of radial head replacement in acute fracture of radial head. J Indira Gandhi Inst Med Sci 2022;8:43-7

How to cite this URL:
Shankar A, Kumar R, Kumar A, Kumar R, Kumar S. Retrospective study to know the outcome of radial head replacement in acute fracture of radial head. J Indira Gandhi Inst Med Sci [serial online] 2022 [cited 2022 Oct 6];8:43-7. Available from: http://www.jigims.co.in/text.asp?2022/8/1/43/338368




  Introduction Top


The fracture of radial head and neck account for 1.5%–4% of all fractures, and for 25%–33% around elbow fractures.[1],[2],[3],[4],[5] When there is associated concomitant ligamentous or osseous injuries around the elbow, proper management of the radial head fracture is necessary to maintain or restore stability.[6],[7]

Indications for surgery includes

(1) Unreconstructible displaced comminuted radial head fractures; (2) Posttraumatic reconstruction of radial head fracture malunions and nonunions; (3) articular displacement; (4) a mechanical block to motion; (5) unstable fractures associated with other osseous or ligamentous injuries about the elbow.[8],[9]

There is a lack of literature regarding the nonunion of undisplaced radial neck fractures. To the best of our knowledge, the first interest in nonunion of the radial neck was in 1905, when Thomas discussed the need for surgical intervention.[1],[10],[11],[12] Published risk factors for the development of nonunion, in general, include smoking, diabetes, use of nonsteroidal anti-inflammatory drugs, advanced age, alcohol abuse, and nutritional deficiency.[1],[13],[14] Other risk factors include the degree of comminution, poor cortical apposition, interposed soft tissues, soft-tissue damage, bone loss, infection, and quality of surgical treatment.[1],[13]

The surgical option for includes open reduction and internal fixation, radial head resection, or radial head arthroplasty.[4],[6],[8],[15],[16],[17],[18],[19]

The treatment of comminuted radial head fractures with open reduction and internal fixation can be challenging. In addition, devastating complications such as increased rates of stiffness, loss of reduction, radial head necrosis, and nonunion can be seen after the internal fixation of comminuted fractures.[6],[15]

Isolated complex radial head injuries can be treated successfully with radial head excision; however, this procedure can cause persistent pain, elbow instability, longitudinal forearm instability, decreased strength, and osteoarthrosis.[6],[15]

Biomechanical studies have already demonstrated that the radial head becomes the main and primary stabilizer against valgus and axial forces across the elbow when radial head fractures are associated with ligamentous or osseous injuries.[6],[7]

Radial head arthroplasty is a suitable technique for the treatment of complex radial head fractures to prevent elbow instability and preserve the distal radioulnar and proximal humeroulnar joints.[6],[20],[21],[22],[23],[24],[25] The literature suggests superior results of replacement over open reduction and internal fixation for unstable complex fractures.[22],[23],[24],[25]

Radial head prostheses are classified based on the type of material from which they are made, their modularity (monoblock or modular), whether unipolar or bipolar, and the type of fixation required.[26] There are good short-term and mid-term data supporting metal and pyrocarbon prostheses.[21],[23],[24],[27],[28],[29] Duckworth et al.[16] have demonstrated a high rate of removal or revision rate for both metallic and silastic implants, with silastic implants and young patients being at the greatest risk of requiring further surgery. The monopolar polyethylene radial head prosthesis was introduced by Sanat metal (Sanat Metal Ltd., Eger, Hungary).[6]

Although numerous studies have demonstrated the outcomes of radial head fractures treated with metallic radial head replacements, most are smaller series with small follow-up.[8],[18],[19],[24],[27],[30],[31],[32] The outcomes of treatment of radial head fracture with a smooth-stemmed, monoblock titanium radial head replacement, at a mean of 12 years, were reported by Harrington et al. in 20012.[18] Since that time, important advances have been made in implant sizing, surgical technique, and understanding of elbow biomechanics.

Short-term outcomes after radial head arthroplasty with a smooth-stemmed modular metallic radial head prosthesis for the treatment of acute radial head fractures were reported in 2006 by Grewal et al.[24] The purpose of the present study was to evaluate the clinical and radiographic outcomes after radial head arthroplasty with a smooth-stemmed metallic prosthesis for the treatment of acute radial head fractures.

Absolute contraindications include

(1) Active joint infection or osteomyelitis of the elbow; (2) Radial head fracture that is amenable to open reduction and internal fixation; (3) Patient systemically not fit for surgery.[4]

Relative contraindications include

(1) Severe ulno-humeral arthritis (2) Severe radio-capitellar arthritis (3) Grade-III open fractures of the radial head should be managed with delayed radial head replacement (4) Patients who are cognitively incapable (e.g., neurologic disorders) of following the postoperative rehabilitation protocol; (5) Chronic radio-capitellar dislocation; (6) Skeletally immature patients; (7) Distant foci of infection.[4]

We used implants from UMA surgicals which comes in various size and thickness of the stem [Figure 1]. The implant is nonmodular plain SS.
Figure 1: Implant used in the study

Click here to view



  Materials and Methods Top


All the patients coming to Patna Bone and Spine Hospital from June 2019 to July 2020 within 7 days of injury giving written consent for the trial, fit for anesthesia, was taken for study. Patients of age group 45 years and above were included in the study. Open injury or lacerated wounds at the site of fracture were not included in the study. Patients having head injury and any serious co-morbid condition were excluded from the study. Contraindications were excluded from the study.

Seven cases were included in this study. All the cases were operated under brachial block anesthesia. Records were made about the sex, mode of injury, time since injury, degree of deformity, side involved, any associated injury around the same elbow noted.

Preoperatively regular radiograph and routine blood investigations needed were carried out and preanesthetic checkup was done.

Operative procedure

Under adequate anesthesia aseptic painting and draping done. Through posterolateral approach [Figure 2] radial head was exposed.
Figure 2: Approach to Radial head

Click here to view


The radial head was taken out completely and reconstructed provisionally on the side table for confirming the completeness of removal. Now measurement of the size of the head was done by comparing it with the head of the prosthesis and noted. Wound lavage was done to remove any left-out bony fragments.

Prosthesis is sterilized as per general instruments of orthopedics. Now the neck of the radius was removed as per the requirement of the prosthesis. Bony edges were made smooth for proper sitting of the prosthesis. Now we rim the medullary canal and accordingly the thickness of stem noted. Now wound lavage was done to remove canal content in the joint. Now appropriate size stem and head prosthesis inserted into the canal and then reduced. Wound lavage was done thoroughly to remove any canal content from the joint. Moreover, it was also checked in the Image intensifier [Figure 3].
Figure 3: Intra operative images after radial head replacement

Click here to view


Annular ligament repair done first and stability checked by the movement of the elbow. Wound closed in layers and range of motion (ROM) checked. Compression dressing is done.

Movement of the elbow started post operatively 1st or 2nd day as per the pain permitting. After 2 days of IV antibiotics, patients were discharged. 1st follow-up was done at the 7th day of operation for wound dressing and follow-up for physiotherapy for ROM. The next follow-up was done at 12–14 days for wound inspection suture removal. The next follow-up was done 6 weeks, 3 months, and 6 months. At these follow-up ROM of the involved elbow was noted [Figure 4] and radiography done [Figure 5].
Figure 4: Flow up clinical picture at 6 weeks

Click here to view
Figure 5: Follow up radiograph at 6 weeks

Click here to view



  Observation and Results Top


Out of seven patients, five were female and two were male. Five had involvement in left and two in right. All patients had a history of direct trauma near the elbow. Four patients had road traffic accident and the rest three had injury in the home either by fall on stairs or slip overground. All of the patients were above 45 years of age [Table 1].
Table 1: Details of the patient

Click here to view


None of the patients had postoperative surgical complications like infection or implant failure. At the end of 6 months, six patients had a satisfactory range of movement except one. One patient had massage done around elbow after 6 weeks of operation even after strict instruction of “no massage.” Which leads to stiffness of the elbow. Radiologically all X-rays were comparable to another side.


  Discussion Top


The clinical and radiographic outcomes at a 6 months after radial head arthroplasty with a smooth-stemmed metallic radial head implant for the treatment of acute radial head fractures are encouraging. Most patients had good objective and subjective clinical outcomes with no apparent functional deterioration from short to longer-term follow-up. None of the implants was removed or revised at the time of the final follow-up.

Although the elbow ROM of the affected limb was less than that of the unaffected limb, the differences were minor and may not be clinically relevant. These results are consistent with previously reported studies with short-term outcomes.[19],[24],[30] The mean flexion ROM of the affected elbow was well within the functional activities of daily living range described by Morrey et al.[7] and was comparable with the functional arc of motion for contemporary tasks described by Sardelli et al.

Minor differences in elbow flexion and extension strength between the affected and unaffected elbows were present at the 6 months follow-up, which is consistent with the findings of other short-term studies.[19],[24],[30] In addition, recovery of strength after surgery is good for a considerable period as there was no significant change during the longitudinal study.

The radiographic assessment revealed outcomes similar to those reported in prior short-term studies of different authors.[19],[24],[30] All implants were found to be of an appropriate size with no evidence of over-lengthening. This may be related to our substantial experience with radial head arthroplasty and surgeon familiarity with this implant at our institution.

Rates of heterotopic ossification vary widely in the literature previously published, and the definition of what constitutes periarticular calcification compared with heterotopic calcification remains unclear. Certainly, longer-term follow-up is needed.[7]

Radial head implant survival rates have varied considerably and may be related to implant design has been reported. Flinkkil¨a et al.,[32] in a series of thirty-seven patients who had acute radial head fractures treated with a press-fit monopolar implant, reported that the implant removal rate was 24% at a mean follow-up of 50 months.

In a study of the outcomes at a mean follow-up of 8.4 years after 51 bipolar radial head arthroplasties performed with cement, Popovic et al.[27] reported that thirty-seven patients had evidence of progressive osteolysis at the bone cement interface, but none had undergone removal of the implant. Most patients had minimal or no pain until the osteolysis became severe. Those authors advised that cemented bipolar implants be used with caution. The 100% implant survivorship in the current study is comparable with the survivorship of smooth stemmed metallic radial head replacements reported by Shore et al. at a mean follow-up of 8 years.


  Conclusions Top


Long-term comparative studies are necessary to make more definitive conclusions. Like many retrospective studies, the present investigation has a number of limitations. Our study population may not be representative of a typical orthopedic practice because of the tertiary referral nature of our center. Radial head arthroplasty with a smooth-stemmed metallic implant is a good treatment option for patients with acute unreconstructible radial head fractures with or without associated osseous and soft-tissue injuries, and sustained clinical outcomes may be expected in further follow-up.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Coury JG, Lum ZC, Trzeciak MA. Nonunion of a nondisplaced radial neck fracture a case report. JBJS Case Connect 2017;7:e70.  Back to cited text no. 1
    
2.
Akesson T, Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Karlsson MK. Primary nonoperative treatment of moderately displaced two-part fractures of the radial head. J Bone Joint Surg Am 2006;88:1909-14.  Back to cited text no. 2
    
3.
Kaas L, van Riet RP, Vroemen JP, Eygendaal D. The epidemiology of radial head fractures. J Shoulder Elbow Surg 2010;19:520-3.  Back to cited text no. 3
    
4.
Longstaffe R, King GJ, Marsh JP. Treatment of radial head fractures with a modular metallic radial head replacement. J Bone Joint Surg Am 2016;98:527-35.  Back to cited text no. 4
    
5.
Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg 1954;42:123-32.  Back to cited text no. 5
    
6.
Ucpunar H, Camurcu Y, Altay R, Duman S, Cobden A, Sofu H. Monoblock polyethylene radial head prosthesis for the treatment of unreconstructable acute radial head fractures with a minimum 1-year follow-up: A retrospective case series. Curr Orthop Pract 2020;31:120-5.  Back to cited text no. 6
    
7.
Morrey BF, Tanaka S, An KN. Valgus stability of the elbow. A definition of primary and secondary constraints. Clin Orthop Relat Res 1991;(265):187-95.  Back to cited text no. 7
    
8.
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;98:527-35.  Back to cited text no. 8
    
9.
Lapner M, King GJ. Radial head fractures. J Bone Joint Surg Am 2013;95:1136-43.  Back to cited text no. 9
    
10.
Cobb TK, Beckenbaugh RD. Nonunion of the radial neck following fracture of the radial head and neck: Case reports and a review of the literature. Orthopedics 1998;21:364-8.  Back to cited text no. 10
    
11.
Thomas TT. XIV. Fractures of the Head and Neck of the Radius. Ann Surg 1907;46:280-91.  Back to cited text no. 11
    
12.
Thomas TT. Fractures of the head of the radius: An experimental study and report of cases. Univ PA Med Bull 1905;18:184-97.  Back to cited text no. 12
    
13.
Niikura T, Lee SY, Sakai Y, Nishida K, Kuroda R, Kurosaka M. Causative factors of fracture nonunion: The proportions of mechanical, biological, patient-dependent, and patient-independent factors. J Orthop Sci 2014;19:120-4.  Back to cited text no. 13
    
14.
Patel RA, Wilson RF, Patel PA, Palmer RM. The effect of smoking on bone healing: A systematic review. Bone Joint Res 2013;2:102-11.  Back to cited text no. 14
    
15.
Hackl M, Wegmann K, Hollinger B, El-Zayat BF, Seybold D, Gühring T, et al. Surgical revision of radial head fractures: A multicenter retrospective analysis of 466 cases. J Shoulder Elbow Surg 2019;28:1457-67.  Back to cited text no. 15
    
16.
Duckworth AD, Wickramasinghe NR, Clement ND, Court-Brown 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;472:2136-43.  Back to cited text no. 16
    
17.
King GJ. Management of comminuted radial head fractures with replacement arthroplasty. Hand Clin 2004;20:429-41.  Back to cited text no. 17
    
18.
Harrington IJ, Sekyi-Otu A, Barrington TW, Evans DC, Tuli V. The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: A long-term review. J Trauma 2001;50:46-52.  Back to cited text no. 18
    
19.
Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ. Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Joint Surg Am 2001;83:1201-11.  Back to cited text no. 19
    
20.
Capo JT, Dziadosz D. Operative fixation of radial head fractures. Curr Orthop Pract 2008;19:264-71.  Back to cited text no. 20
    
21.
Burkhart KJ, Mattyasovszky SG, Runkel M, Schwarz C, Küchle R, Hessmann MH, et al. Mid-to longterm results after bipolar radial head arthroplasty. J Shoulder Elbow Surg 2010;19:965-72.  Back to cited text no. 21
    
22.
Chen X, Wang SC, Cao LH, Yang GQ, Li M, Su JC. Comparison between radial head replacement and open reduction and internal fixation in clinical treatment of unstable, multi-fragmented radial head fractures. Int Orthop 2011;35:1071-6.  Back to cited text no. 22
    
23.
Doornberg JN, Parisien R, van Duijn PJ, Ring D. Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. J Bone Joint Surg Am 2007;89:1075-80.  Back to cited text no. 23
    
24.
Grewal R, MacDermid JC, Faber KJ, Drosdowech DS, King GJ. Comminuted radial head fractures treated with a modular metallic radial head arthroplasty. Study of outcomes. J Bone Joint Surg Am 2006;88:2192-200.  Back to cited text no. 24
    
25.
Ruan HJ, Fan CY, Liu JJ, Zeng BF. A comparative study of internal fixation and prosthesis replacement for radial head fractures of Mason type III. Int Orthop 2009;33:249-53.  Back to cited text no. 25
    
26.
Heijink A, Kodde IF, Mulder PG, Van Dijk CN, Eygendaal D. Cemented bipolar radial head arthroplasty: Midterm follow-up results. J Shoulder Elbow Surg 2016;25:1829-38.  Back to cited text no. 26
    
27.
Popovic N, Lemaire R, Georis P, Gillet P. Midterm results with a bipolar radial head prosthesis: Radiographic evidence of loosening at the bone-cement interface. J Bone Joint Surg Am 2007;89:2469-76.  Back to cited text no. 27
    
28.
Ricón FJ, Sánchez P, Lajara F, Galán A, Lozano JA, Guerado E. Result of a pyrocarbon prosthesis after comminuted and unreconstructable radial head fractures. J Shoulder Elbow Surg 2012;21:82-91.  Back to cited text no. 28
    
29.
Junkiewicz MR, Clemente JS, Miller MC, Baratz ME, Wysocki RW, Cohen MS. Radial head replacement with a bipolar system: A minimum 2-year follow-up. J Shoulder Elbow Surg 2012;21:98-104.  Back to cited text no. 29
    
30.
Ashwood N, Bain GI, Unni R. Management of Mason type-III radial head fractures with a titanium prosthesis, ligament repair, and early mobilization. J Bone Joint Surg Am 2004;86:274-80.  Back to cited text no. 30
    
31.
Shore BJ, Mozzon JB, MacDermid JC, Faber KJ, King GJ. Chronic posttraumatic elbow disorders treated with metallic radial head arthroplasty. J Bone Joint Surg Am 2008;90:271-80.  Back to cited text no. 31
    
32.
Flinkkil¨a T, Kaisto T, Sirni¨o K, Hyv¨onen P, Leppilahti J. Short-to mid-term results of metallic press-fit radial head arthroplasty in unstable injuries of the elbow. J Bone Joint Surg Br 2012;94:805-10.  Back to cited text no. 32
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

Top
 
 
  Search
 
Similar in PUBMED
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Observation and ...
Discussion
Conclusions
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed288    
    Printed20    
    Emailed0    
    PDF Downloaded27    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]