|Year : 2022 | Volume
| Issue : 1 | Page : 43-47
Retrospective study to know the outcome of radial head replacement in acute fracture of radial head
Anand Shankar1, Rishabh Kumar1, Ashutosh Kumar1, Rakesh Kumar1, Santosh Kumar2
1 Department of Trauma and Emergency (Orthopaedics), IGIMS, Patna, Bihar, India
2 Department of Orthopaedics, IGIMS, Patna, Bihar, India
|Date of Submission||17-Jan-2022|
|Date of Acceptance||24-Jan-2022|
|Date of Web Publication||12-Feb-2022|
Assistant Professor, Department of Trauma and Emergency (Orthopaedics), IGIMS, Raja Bajar, Seikhpura, Patna - 800 014, Bihar
Source of Support: None, Conflict of Interest: None
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|| |
The fracture of radial head and neck account for 1.5%–4% of all fractures, and for 25%–33% around elbow fractures.,,,, 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.,
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.,
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.,,, 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.,, 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.,
The surgical option for includes open reduction and internal fixation, radial head resection, or radial head arthroplasty.,,,,,,,
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.,
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.,
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.,
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.,,,,,, The literature suggests superior results of replacement over open reduction and internal fixation for unstable complex fractures.,,,
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. There are good short-term and mid-term data supporting metal and pyrocarbon prostheses.,,,,, Duckworth et al. 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).
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.,,,,,,, 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. 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. 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.
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.
We used implants from UMA surgicals which comes in various size and thickness of the stem [Figure 1]. The implant is nonmodular plain SS.
| Materials and Methods|| |
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.
Under adequate anesthesia aseptic painting and draping done. Through posterolateral approach [Figure 2] radial head was exposed.
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].
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].
| Observation and Results|| |
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].
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|| |
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.,, The mean flexion ROM of the affected elbow was well within the functional activities of daily living range described by Morrey et al. 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.,, 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.,, 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.
Radial head implant survival rates have varied considerably and may be related to implant design has been reported. Flinkkil¨a et al., 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. 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|| |
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]