Clinical and radiographic comparisons of two different radial head implant designs

doi:10.1016/j.jse.2013.02.011

Journal of Shoulder and Elbow Surgery

Volume 22, Issue 8, August 2013, Pages 1108-1120

https://doi.org/10.1016/j.jse.2013.02.011 Get rights and content

Background

There is little comparative data to guide implant choice for radial head replacements. The purpose of this study was to evaluate the clinical and radiographic results between patients who received a smooth-stemmed bipolar radial head implant and patients who received an in-growth monopolar prosthesis.

Methods

Twenty-seven patients requiring a metallic radial head implant in the management of acute or chronic elbow trauma were evaluated. Fourteen patients received a smooth-stemmed bipolar prosthesis and 13 patients received a press-fit monopolar prosthesis. Patients returned for follow-up at an average of 33 months (range, 18-57). Outcome assessments included joint motion, elbow stability, grip strength, pain, the Mayo Elbow Performance Index, and the Disability of Arm, Shoulder and Hand questionnaire. Radiographs were reviewed for joint congruence, ectopic bone, periprosthetic osteolysis, degenerative arthritis, and capitellar wear, and selected patients were tested for inflammatory markers and metal ion levels.

Results

The differences between patient groups for elbow flexion and forearm pronation averaged 10° or less. There were no other pertinent differences between groups for standardized patient and examiner-determined outcomes. There was a trend for ectopic bone to develop more commonly around the smooth-stemmed implants, while periprosthetic osteolysis was more pronounced in cases with the press-fit design. Inflammatory markers were normal, and metal ion levels did not exceed values reported for a well-functioning hip arthroplasty.

Conclusion

Outcomes at short- to mid-term follow-up were similar with either implant design. Loosening of a press-fit prosthesis may lead to extensive osteolysis, but of undetermined clinical consequence.

Section snippets

Patient demographics and treatment

Thirty-four patients who underwent unilateral radial head implant arthroplasty with a specific prosthetic design in the surgical management of an acute or chronic elbow injury were identified retrospectively from the personal databases of 5 hand surgeons and 1 orthopedic traumatologist between 2004 and 2010. Twenty-one patients received a smooth-stemmed bipolar implant (Katalyst Bipolar Radial Head System, Integra Life Sciences Corporation, Plainsboro, NJ, USA), and 13 patients received an

Clinical outcomes

The mean ages of the patients were similar between groups 1 and 2 (P = .47). In the injured extremities, elbow flexion was greater in group 1 patients, whereas forearm pronation was greater in group 2 patients (P < .05). The differences in motion averaged 10 degrees or less. In the uninjured extremities, forearm pronation was greater in group 2 patients. There were no other significant differences between the groups for measurements of joint motion, grip strength, VAS pain values, MEPI scores,

Discussion

The radial head provides an important valgus buttress to the elbow, particularly in the setting of an incompetent medial collateral ligament complex, and is an integral factor in maintaining forearm longitudinal stability after injury to the interosseous membrane and triangular fibrocartilage complex.³ While open repair of a comminuted and displaced radial head fracture may be feasible, metallic radial head implant arthroplasty is often considered given the technical challenges of

Conclusion

Based on the results of our study, smooth-stemmed bipolar and in-growth monopolar implants can lead to acceptable clinical outcomes in the management of elbow injuries at short- to mid-term follow-up. Proximal radial ectopic bone formation is expected in association with both implant designs. A thin radiolucency may develop around a smooth-stemmed implant, whereas limited bone resorption may occur beneath the neck of a well-fixed press-fit prosthesis. Expansile periprosthetic osteolysis can

Acknowledgment

The authors would like to thank Leon S. Benson, MD, John J. Fernandez, MD, and Richard L. Makowiec, MD, for contributing patients to this study, and Mary Kwasny for assistance with the statistical analyses.

Disclaimer

Drs. Kalainov, Wysocki, and Cohen have served as consultants for Acumed. Dr. Cohen is a consultant for Integra LifeSciences Corporation. The authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

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Cited by (73)

Radiographic and clinical comparisons between loose-fit and press-fit stems in monopolar radial head arthroplasty for comminuted radial head fractures
2024, Journal of Orthopaedic Science
Few clinical studies have compared the operative outcomes between loose- and press-fit stems in radial head arthroplasty (RHA). We aimed to evaluate the radiographic and clinical results of the two radial head implant concepts.
In this retrospective multicenter study, 32 patients (24 women and 8 men) with a mean age of 63.1 years who underwent RHA for comminuted radial head fractures were reviewed between 2005 and 2021. Seventeen patients underwent RHA with a loose-fit stem (L-group), whereas the remaining fifteen patients underwent RHA with a press-fit stem (P-group). The mean follow-up period was 40.1 ± 9.9 months, with the minimum follow-up duration of 12 months. The radiographic findings were evaluated for periprosthetic osteolysis; furthermore, clinical outcomes were analyzed to measure the range of motion of the elbow. The rate of reoperations and prosthesis removal were also reviewed.
The general characteristics of the patients were similar in the two groups. The rate of periprosthetic osteolysis was 17.6% in the L-group, whereas it was 53.3% in the P-group. The mean elbow flexions were 128° and 133° in the L- and P-groups, respectively. The mean elbow extensions were −12° and −9° in the L- and P-groups, respectively. The rate of reoperation was 23.5% in the L-group and 15.2% in the P-group. One patient in the L-group had the prosthesis removed because of surgical site infection, whereas one patient in the P-group had the prosthesis removed owing to painful loosening.
No significant differences in the clinical outcomes and reoperation rate were observed between the two radial head implant concepts in this study. However, osteolysis occurred more frequently in the P-group. Although patients with periprosthetic osteolysis are currently asymptomatic, they should be carefully followed up for the symptoms in the long term.
Radial head replacement for acute complex elbow instability: a long-term comparative cohort study of 2 implant designs
2023, Journal of Shoulder and Elbow Surgery
Radial head fractures not amenable to reconstruction should be treated by radial head replacement (RHR) when there is associated elbow or forearm instability. There are multiple RHR designs with different philosophies, but 2 of the most commonly used implants include the anatomic press-fit radial head system and the loose-fit metallic spacer. There is little information available specifically comparing the long-term clinical and radiographic outcomes of these 2 systems. The objective of this study was to compare the long-term clinical and radiologic outcomes of 2 RHR designs in the context of complex acute elbow instability.
Ninety-five patients with an average age of 54 years (range, 21-87 years) underwent an acute RHR (46 press-fit Acumed anatomic and 49 loose-fit Evolve metallic spacer) and were prospectively followed for an average of 61 months (range, 24-157 months). There were 34 terrible triads; 36 isolated RH fractures with medial, lateral, or longitudinal instability; and 25 RH fractures associated with a proximal ulnar fracture. Clinical outcome and disability were evaluated with the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score, and the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Pain and satisfaction were assessed using a visual analog scale. Radiographic analysis included presence of loosening, bone loss, and overstuffing related to the RHR.
Eight patients with an anatomic RHR (2 with overstuffing, 3 for stiffness, and 3 with loose implants) and 1 patient with a spacer (with stiffness) required implant removal. There were no significant differences between spacer RHR and anatomic RHR in arc of motion (120° vs. 113°, P = .14), pain relief (1 vs. 1.7, P = .135), MEPS (94 vs. 88; P = .07), Oxford Elbow Score (42.3 vs. 42.2, P = .4), or DASH score (12.2 vs. 14.4, P = .5). However, patients with a spacer RHR were significantly more satisfied (9 vs. 7.7; P = .004) than those with an anatomic implant. Radiographically, 19 anatomic implants had significant proximal bone loss and 10 showed complete lucent lines around the stem. Lucent lines were common around the spacer RHR. These radiographic changes were not always related to worse clinical outcomes.
Both the anatomic and spacer RHR designs can provide good clinical long-term outcomes. However, patients with a spacer showed a higher degree of satisfaction and those with an anatomic press-fit RHR had a higher revision rate, with radiographic changes that warrant continued follow-up
The Boyd approach: a valuable alternative to treating simple to complex elbow fractures and dislocations
2023, Journal of Shoulder and Elbow Surgery
The Boyd approach is a single-incision posterior approach to the proximal radius and ulna based on a lateral anconeus muscle reflection and release of the lateral collateral ligamentous complex. This approach remains a lesser-used technique following early reports of proximal radioulnar synostosis and postoperative elbow instability. Although limited by small case series, recent literature does not support these early reported complications. This study presents a single surgeon’s outcomes using the Boyd approach for the treatment of simple to complex elbow injuries.
Following institutional review board approval, a retrospective review of all patients with simple to complex elbow injuries treated consecutively using a Boyd approach by a shoulder and elbow surgeon was conducted from 2016 to 2020. All patients with at least 1 postoperative clinic visit were included. Data collected included patient demographics, injury description, postoperative complications, elbow range of motion, and radiographic findings including heterotopic ossification and proximal radioulnar synostosis. Categorical and continuous variables were reported using descriptive statistics.
A total of 44 patients were included with an average age of 49 years (range 13-82 years). The most commonly treated injuries were Monteggia fracture-dislocations (32%) and terrible triad injuries (18%). Average follow-up was 8 months (range 1-24 months). Final average elbow active arc of motion was from 20° (range 0°-70°) of extension to 124° (range 75°-150°) of flexion. Final supination and pronation were 53° (range 0°-80°) and 66° (range 0°-90°), respectively. There were no cases of proximal radioulnar synostosis. Heterotopic ossification contributing to less than functional elbow range of motion occurred in 2 (5%) patients who elected conservative management. There was 1 (2%) case of early postoperative posterolateral instability due to repair failure of injured ligaments that required revision using a ligament augmentation procedure. Five (11%) patients experienced postoperative neuropathy, including 4 (9%) with ulnar neuropathy. Of these, 1 underwent ulnar nerve transposition, 2 were improving, and 1 had persistent symptoms at final follow-up.
This is the largest case series available demonstrating the safe utilization of the Boyd approach for the treatment of simple to complex elbow injuries. Postoperative complications including synostosis and elbow instability may not be as common as previously understood.
Radial neck osteolysis after radial head replacement: Functional impact and risk factors
2023, Orthopaedics and Traumatology: Surgery and Research
Onset of radial neck osteolysis (RNO) has been reported after radial head replacement (RHR), but data are sparse regarding impact and risk factors. We therefore conducted a retrospective study, 1) to quantify RNO after RHR, 2) to assess clinical and radiological impact, and 3) to identify risk factors.
RNO prevalence is high, but functional impact is limited.
A single-center retrospective study included all patients undergoing RHR for acute radial head fracture between 2008 and 2017: 53 patients, with a mean age of 53.8 ± 15.7 years [range, 21–85 years]. At a minimum 2 years’ follow-up, patients were assessed clinically on joint range of motion and Mayo Elbow Performance Score (MEPS) and radiologically on standard radiographs. Associations between RNO and various parameters were assessed.
At a mean 46.7 ± 19.8 months’ follow-up [range, 24–84 months], RNO was found in 54.7% of cases (29/53), with mean 4.0 ±2.8 mm distal extension [range, 1.2–13.4 mm], corresponding to 13.4 ± 7.3% of stem height [range, 2.7–27.7%].
RNO at last follow-up was not significantly associated with reduced flexion-extension (121.9° versus 114.0°; p = 0.11), pronation-supination (152.6° versus 138.3°; p = 0.25) or MEPS (84.7 versus 84.8; p = 0.97), or with higher rates of postoperative complications (11/29 (37.9%) versus 7/24 (29.2%); p = 0.782) or surgical revision (11/29 (37.9%) versus 10/24 (41.7%); p = 0.503).
RNO was significantly associated with cementless fixation (19/29 (65.5%) versus 7/24 (29.2%); p = 0.01), unipolar prosthesis (21/29 (72.4%) versus 7/24 (29.2%); p = 0.002), high filling-ratio, whether proximal (88% versus 77%; p = 0.002), middle (84% versus 75%; p = 0.007) or distal (69% versus 59%; p = 0.032), and shorter radial stem (33.2 mm versus 46.3 mm; p = 0.011). No demographic parameters showed significant association with RNO at last follow-up.
RNO was frequent after RHR, but without clinical or radiological impact in the present series. The risk factors identified here argue for involvement of stress shielding.
IV, cohort study.
Radial neck osteolysis after radial head replacement: Functional impact and risk factors
2023, Revue de Chirurgie Orthopedique et Traumatologique
L’apparition d’une ostéolyse du col du radius (OCR) après arthroplastie de tête radiale (ATR) est un phénomène décrit dans la littérature. Peu de données sont publiées concernant ses conséquences et les facteurs favorisants sa survenue. Aussi, nous avons mené une étude rétrospective avec pour objectifs (1) de quantifier la prévalence d’OCR après ATR, (2) d’évaluer le retentissement clinique et radiologique de cette OCR, (3) d’identifier des facteurs associés.
La prévalence de l’OCR serait élevée mais les conséquences fonctionnelles limitées.
Nous avons mené une étude rétrospective monocentrique incluant tous les patients opérés d’une ATR de première intention pour une fracture de la tête radiale prise en charge en situation aiguë entre 2008 et 2017. Il s’agissait de 53 patients, d’âge moyen 53,8 ± 15,7 [21–85]. Au recul minimum de 2 ans, les patients ont été évalués cliniquement (amplitudes articulaires et Mayo Elbow Performance Score [MEPS]) et radiologiquement (radiographies standards). Des associations statistiques entre la présence d’OCR et différents paramètres ont été recherchées.
Au recul moyen de 46,7 mois ± 19,8 [24–84], une OCR était présente dans 54,7 % (29/53) des cas, s’étendant en distal de 4,0 mm ± 2,8 [1,2–13,4] en moyenne, correspondant à 13,4 % ± 7,3 [2,7–27,7] de la hauteur de la tige. La présence d’une OCR au dernier recul n’était statistiquement pas associée à une diminution de la mobilité en flexion-extension (121,9° contre 114,0° [p = 0,11]) ou en prono-supination (152,6° contre 138,3° [p = 0,25]), avec le MEPS (84,7 points contre 84,8 points [p = 0,97]), ni à la survenue d’une complication postopératoire (11/29 [37,9 %] contre 7/24 [29,2 %], p = 0,782) ou d’une réintervention (11/29 [37,9 %] contre 10/24 [41,7 %], p = 0,503). La présence d’une OCR était associée à : une fixation sans ciment (19/29 [65,5 %] contre 7/24 [29,2 %], p = 0,01), le caractère monopolaire de la prothèse (21/29 [72,4 %] contre 7/24 [29,2 %], p = 0,002), un filling-ratio élevé en proximal (88 % contre 77 % [p = 0,002]), médian (84 % contre 75 % [p = 0,007]) et distal (69 % contre 59 % [p = 0,032]), une longueur moindre de la tige radiale (33,2 mm contre 46,3 mm [p = 0,011]). Aucun des paramètres démographiques étudiés ne présentait d’association statistique significative avec la présence d’une OCR au dernier recul.
L’OCR après ATR est un phénomène fréquent, sans conséquence identifiée dans notre série sur les résultats cliniques et radiologiques. Les facteurs favorisants identifiés plaident en faveur d’une origine liée au stress shielding.
IV ; étude de cohorte.
Radial head replacement – A comprehensive review
2023, Journal of Orthopaedics
Radial head fractures represent 1–4% of all adult fractures and 1/3rd of elbow fractures (Kaas et al., 2010). Radial head is an important secondary stabilier of the elbow. The aim of the treatment of radial head fractures is to achieve stability and good functional outcome. Radial head replacement (RHR) is indicated when robust reconstruction and fixation of the fracture fragments is not possible.
This article explores history and evolution, anatomical considerations, biomechanics, implant designs, indications, surgical outcomes and controversies in radial head replacement based on current evidence.
There is a wide range of RHR designs available without conclusive evidence to support the superiority of one design over the other. Ranges of motion, functional outcomes and complication were comparable among different designs with a high incidence of complications reported in many studies.
RHR remains a good option in unreconstructible radial head fractures, with potential to regain excellent function. It is imperative to continue with the quest to innovate and improve on current designs, to reduce complications in the long term.

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: IRB: Northwestern University #CR2_STU00008411, Rush University Medical Center #07121902.

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ElbowClinical and radiographic comparisons of two different radial head implant designs

Background

Methods

Results

Conclusion

Section snippets

Patient demographics and treatment

Clinical outcomes

Discussion

Conclusion

Acknowledgment

Disclaimer

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Hand Surg Am

J Shoulder Elbow Surg

J Hand Surg Am

J Hand Surg Am

J Shoulder Elbow Surg

Hand Clin

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Contralateral elbow radiographs can reliably diagnose radial head implant overlengthening

J Bone Joint Surg Am

Review of periprosthetic osteolysis in total joint arthroplasty: an emphasis on host factors and future directions

J Orthop Res

The effect of radial head excision and arthroplasty on elbow kinematics and stability

J Bone Joint Surg Am

Results of delayed excision of the radial head after fracture

J Bone Joint Surg Am

Elbow
Clinical and radiographic comparisons of two different radial head implant designs