Comparative Study between Surgical Excision of Radial Head Fracture versus Arthroplasty, a Systematic Review of Literature

Background Radial head fracture is the most frequently diagnosed fracture of the elbow in adults. The radial head is a secondary valgus stabilizer of the joint and it is involved in transmission of axial force load through the elbow during flexion. It is also a varus and external rotatory constraint. Aim of the Work to compare the functional outcome between excision of head radius and Arthroplasty in surgical management of radial head fractures (Mason types III and IV) and to assess the complications of both techniques. Patients and methods This systemic review included subjects suffered comminuted radial head fracture Mason type III or type IV treated by radial head excision or arthroplastyin the last 14 years from 2004 till 2018. Results: The database search identified 152 potentially relevant articles. Abstracts have been analyzed following inclusion and exclusion criteria and a total of 17 papers were selected for the present review. Most of retrospective studies on metal radial head prosthesis have been published in the last ten years in comparison to a lack of studies for radial head excision in the last two decades. Moreover, few articles on comparison of the two surgical techniques have been found. Because of heterogeneity in level of evidence, surgical technique, type of implants, and rehabilitation protocol, we did not perform statistical data analysis. Conclusion No clinical differences between radial head excision and arthroplasty as both methods are considerable regarding complication on long & mid-term follow up and functional outcome assessed by DASH, VAS, MEPS & ROM.

Extracorporeal Reconstruction of the Radial Head

Radial head fractures are common in adults. The radial head acts as an important stabilizer of the radius, especially during the forearm pronation and supination. Surgical treatment of Mason type III fracture of the radial head includes radial head excision, radial head replacement and open reduction and internal fixation. For patients treated with radial head excision, the radius might migrate proximally, causing complications such as chronic pain at the wrist, forearm, and elbow. On the other hand, radial head arthroplasty is associated with a high revision and removal rate. Hence, openreduction and internal fixation are preferred when feasible. This is technically demanding due to the severe displacement of the radial head fragments and limited surgical space. Mr K, a 30-year-old manual worker sustained a closed right radial head fracture Mason type III after an alleged fall. The radial head was displaced anteriorly. Intra-operatively, the radial headpieces were retrieved and were reconstructed extracorporeal and fixed with a miniplate. The patient subsequently recovered with good function. The new technique of extracorporeal reconstruction of the radial head offers a viable option to the surgeon with similar, or even better, outcomes in terms of elbow function.

Acute Radial Head Resection for Fracture: are We Likely to Miss an Essex-Lopresti Injury?

Background. Given the current available evidence, surgical treatment of radial head fracture with acute resection is controversial. The aim of this study was to determine whether acute resection of the radial head for a radial head fracture leads to longitudinal forearm instability due to a missed Essex-Lopresti injury. Material and methods. A retrospective review was conducted of radial head resections performed for acute radial head fractures at two Level I trauma centers from 2000 to 2018. A total of 11 patients met inclusion criteria. Our primary outcome was a missed Essex-Lopresti injury at time of final clinical follow-up. Long-term telephone follow-up was attempted for QuickDASH, pain scores, and satisfaction scores. Results. Of the 11 radial head fractures in this study, intraoperative radial pull tests were performed and normal in 6 patients. No patient was found to have a missed Essex-Lopresti injury at a mean of 36.2 months’ clinical follow-up after radial head resection. At a mean telephone follow-up of 12.6 years in available patients, mean QuickDASH was 3.4, mean satisfaction was 9.75 out of 10, and no further complication or reoperation was reported. Conclusion. Our findings challenge the dogma that the radial head cannot be safely excised in the setting of acute fracture, even with elbow instability and/or wrist pain, particularly when intraoperative longitudinal stability is assessed by a stress maneuver.

Elbow Instability

The stability of the elbow is based on a combination of primary (static) and secondary stabilizers (dynamic). In varus stress, the bony structures and the lateral ulnar collateral ligament (LUCL) are the primary stabilizers, and in valgus stress, the ulnar collateral ligament (UCL) is the primary stabilizer. The flexor and extensor tendons crossing the elbow joint act as secondary stabilizers. Elbow instability is commonly divided into acute traumatic and chronic instability. Instability of the elbow is a continuum, with complete dislocation as its most severe form.Posterolateral rotatory instability is the most common elbow instability and can be detected at imaging both in the acute as well as the chronic phase. Imaging of suspected elbow instability starts with radiographs. Depending on the type of injury suspected, it is followed by magnetic resonance imaging (MRI) or computed tomography evaluation for depiction of a range of soft tissue and osseous injures. The most common soft tissue injuries are tears of the LUCL and the radial collateral ligament; the most common osseous injuries are an osseous LUCL avulsion, a fracture of the coronoid process, and a radial head fracture.Valgus instability is the second most common instability and mostly detected in the chronic phase, with valgus extension overload the dominant pattern of injury. The anterior part of the UCL is insufficient in valgus extension overload due to repetitive medial tension seen in many overhead throwing sports, with UCL damage readily seen at MRI.

Short term outcome of radial head arthroplasty in Mason type 3 and 4 fractures

<p class="abstract"><strong>Background:</strong> Radial head arthroplasty provides a suitable treatment in Mason type 3 and 4 3 fractures. Arthroplasty produces consistent results with a shorter learning curve than ORIF and prevents the late complications associated with radial head excision.</p><p class="abstract"><strong>Methods: </strong>After seeking approval from local institutional ethical committee 30 patients with Mason type 3 and 4 radial head fractures were admitted from outpatient department (OPD) of SKIMS MC and Hospital Bemina, Srinagar. The study was conducted from February 2019 to June 2020 in department of Orthopaedics SKIMS MC and Hospital Bemina, Srinagar. 30 patients with mean age of 25 years comprising of 9 females and 21 males underwent radial head arthroplasty and were followed up to a minimum of 1 year post-operatively.</p><p class="abstract"><strong>Results: </strong>Outcome was evaluated by assessing elbow functional performance using Mayo elbow performance (MEPI). No revisions were performed during the study. Two patients had implant backout and 6 patients had elbow stiffness.</p><p class="abstract"><strong>Conclusions: </strong>Radial head arthroplasty can be used successfully with most of excellent results for treatment of comminuted radial head fracture (Mason type III and IV radial head fractures). Over all radial head arthroplasty is a demanding option in type 3 and type 4 fractures which are not amenable to reconstruction.</p>