The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 5

Scientific Articles | May 01, 2007

Radial Head Arthroplasty with a Modular Metal Spacer to Treat Acute Traumatic Elbow Instability

Job N. Doornberg, MS¹; Robert Parisien, MD¹; P. Joppe van Duijn, BS¹; David Ring, MD¹

¹ Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114. E-mail address for J.N. Doornberg: jdoornberg@partners.org. E-mail address for D. Ring: dring@partners.org

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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the AO Foundation, Wright Medical Technology, Joint Active Systems, Smith and Nephew, and Small Bone Innovations. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Investigation performed at the Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 May 01;89(5):1075-1080. doi: 10.2106/JBJS.E.01340

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Abstract

Background: The use of a metal radial head prosthesis to help stabilize an elbow with traumatic instability is appealing because internal fixation of multifragment, displaced fractures of the radial head is susceptible to either early or late failure. The newer modular prostheses are easier to size and implant, but their effectiveness has not been investigated, to our knowledge.

Methods: Twenty-seven patients in whom a radial head replacement with a modular metal spacer prosthesis had been performed to treat traumatic elbow instability were evaluated with use of the Mayo Elbow Performance Index (MEPI), the American Shoulder and Elbow Surgeons Elbow Evaluation Instrument (ASES), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Radiographs were evaluated for arthrosis, periprosthetic radiolucency, and heterotopic ossification.

Results: Seven patients underwent one or more subsequent operations to treat residual instability, heterotopic ossification and elbow contracture, ulnar neuropathy, or a misplaced screw. In two of these patients, the prosthesis was removed as part of an elbow contracture release or to treat infection. At an average of forty months postoperatively, elbow motion in the entire group of twenty-seven patients averaged 131° of flexion with a 20° flexion contracture, 73° of pronation, and 57° of supination. Stability was restored to all twenty-seven elbows, and twenty-two patients had a good or excellent result according to the MEPI. Seventeen patients had radiographic evidence of lucency around the neck of the prosthesis that was not associated with increased pain, thirteen patients had clinically inconsequential heterotopic ossification anterior to the radial neck, and nine patients had radiographic changes in the capitellum.

Conclusions: An intentionally loosely placed modular metal radial head prosthesis can help to restore stability in conjunction with repair of other fractures and reattachment of the lateral collateral ligament to the epicondyle in the setting of traumatic elbow instability with a comminuted fracture of the radial head. While a prosthesis that is too large can cause problems, lucencies around the stem of the intentionally loose prosthesis and most changes in the capitellum do not appear to cause problems, at least in the short term.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

The radial head has been recognized as an important stabilizer of the forearm and elbow¹. Replacement of the fractured radial head with a prosthesis is a useful treatment option when the forearm or elbow is unstable and internal fixation is tenuous, likely to fail, or impossible to achieve^2-4. Silicone rubber implants were popular for a while, but it is now well recognized that a metal implant provides greater stability^5,6. Silicone implants also can fragment and cause synovitis⁷.

It is difficult to replicate the complex anatomy of the proximal part of the radius with a prosthesis^8-14. As a result, most prostheses have evolved on the basis of one of two broad designs: (1) a stem that is rigidly fixed to the radial neck and a mobile head^15,16 or (2) a smooth polished stem that, when implanted, is intentionally loose so that the prosthesis acts as a metal spacer that has enough mobility to adapt to the complex anatomy^17,18.

In this study, we investigated the use of a modular metal radial head prosthesis with a smooth neck that was intentionally inserted loose to create a metal spacer arthroplasty. Specifically, we sought to determine the success of this prosthesis in helping to stabilize the elbow to treat acute traumatic elbow instability and to identify drawbacks of this technique.

Materials and Methods

Materials and Methods | Results | Discussion | References

Over a four-year period, one surgeon (D.R.) performed prosthetic replacement of a fractured radial head in thirty-seven consecutive patients with traumatic elbow instability that was considered to be acute (i.e., treated within three weeks after the injury). A single type of modular metal prosthesis with a smooth stem that was intentionally inserted loose (Evolve; Wright Medical Technology, Arlington, Tennessee) was used throughout the study period. The human research committee at our institution approved a protocol for retrospective review of medical records and radiographs and reevaluation of patients after informed consent was obtained. Twenty-seven patients returned for a comprehensive physical and radiographic evaluation according to the Mayo Elbow Performance Index (MEPI)¹⁹ and the Elbow Surgeons Elbow Evaluation Instrument²⁰ (ASES) and completion of the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH)²¹. Ten of the thirty-seven patients had been followed for fewer than twenty-four months and either could not be contacted or declined to participate.

Patients

There were thirteen men and fourteen women with an average age of fifty-two years (range, twenty-two to seventy-one years). The left arm was involved in sixteen patients, and one of those arms was dominant. The right arm was involved in eleven patients, and six of those arms were dominant. Twenty-one patients were injured in a fall from a standing height and six, in a fall from a greater height.

Ten radial head fractures were associated with a posterior fracture-dislocation of the olecranon and a fracture of the coronoid, sixteen were associated with a complete posterior dislocation of the elbow (with thirteen of them also associated with a fracture of the coronoid—the so-called terrible triad of the elbow²²), and one was associated with a rupture of the medial collateral ligament with subluxation but not complete dislocation of the elbow.

At the time of the operative exposure, the radial head fracture was classified, according to the system described by Mason²³, as Type 2 (a partial head fracture with more than a small marginal fragment) in eleven patients and as Type 3 (a fracture of the entire head) in sixteen patients. In this series, and in our experience in general, partial fractures of the radial head in the setting of complex elbow instability consistently involved >30% of the surface area of the radial head. These fractures also involved the most important, anterolateral portion of the head, which acts as a buttress against posterior dislocation. Finally, these fractures were often comminuted and widely displaced, resulting in lost fragments and fragments that were too small to repair. The indication for prosthetic replacement of the fractured radial head in the setting of traumatic elbow instability was either a fracture of the whole head (Mason Type 3) with more than three articular fragments or any fracture with lost or irreparable fragments.

One patient had an ipsilateral scaphoid fracture, and one had an associated acute carpal tunnel syndrome. Four patients had multiple skeletal injuries, including three with a contralateral distal radial fracture and one with a contralateral olecranon fracture.

Operative Technique

The patients were placed in either the lateral decubitus position with the arm supported on a pillow bolster (when they had an olecranon fracture-dislocation) or supine with the arm supported on a hand-table (when they had any other type of injury). A dorsal midline skin incision was used^24,25. The ten fractures of the olecranon were fixed with a contoured dorsal plate: eight of them were treated with a 3.5-mm limited-contact dynamic compression plate (Synthes, Paoli, Pennsylvania) with an average of eleven holes (range, nine to fourteen holes), and two were treated with a plate designed specifically for the proximal part of the ulna (Mayo Clinic Congruent Elbow Plate; Acumed, Beaverton, Oregon). Nine of these patients had an associated fracture of the coronoid that was secured with screws placed from dorsal to volar either through or adjacent to the plate (eight patients) or secured with suture alone (one patient). In one patient with a comminuted and irreparable fracture of the coronoid, a piece of the radial head was used to reconstruct the coronoid. The elbow of this patient was protected in a hinged external fixator for five weeks. Twelve of the thirteen patients with a terrible triad injury had repair of a small transverse coronoid fracture with sutures placed through drill-holes in the ulna²⁶.

The lateral collateral ligament was inspected in every patient, and the origin of this ligament was found to be avulsed from the lateral epicondyle in all sixteen patients with an elbow dislocation and in eight of the ten with a posterior olecranon fracture. The origin of the injured lateral collateral ligament was reattached to the lateral epicondyle with use of suture anchors (G2; DePuy Mitek, Norwood, Massachusetts) in twenty patients and with use of sutures placed through drilled holes in four patients. Braided, nonabsorbable 2-0 suture was used with both techniques.

The medial collateral ligament was not routinely explored. In two patients, the origin of the medial collateral ligament was reattached to the medial epicondyle with Mitek suture anchors (DePuy Mitek). The ulnar nerve was decompressed in ten patients. In four of these patients, subcutaneous anterior transposition of the ulnar nerve was performed when the nerve was mobilized to repair the medial collateral ligament (two patients), to facilitate repair of a complex coronoid fracture (one patient), or for placement of a hinged external fixator (one patient). In situ release was performed in the remaining six patients treated with ulnar nerve decompression.

The largest radial head fragments were retrieved and were used to assist in the selection of the size of the prosthesis. Any portion of the radial head that remained attached to the radial neck was removed with an osteotome, but no attempt was made to plane down slight irregularities in the neck of the radius. No radial neck defects that were large enough to allow escape or dislocation of the prosthesis were encountered in this series of patients. The radial neck was reamed to remove cancellous bone, with little or no reaming of cortical bone. The neck size that was selected was one size smaller than the size of the final reamer—i.e., the one that began to ream cortical bone.

The thickness (longitudinal height) of the prosthetic head was selected on the basis of the radial head fracture fragments, with use of trial prostheses for comparison. If the neck is not planed flat—as it was not in this series of patients—it is important to measure from the thinnest portion of the head (the area where the prosthesis will rest on the neck of the radius) in order to avoid placing a prosthesis that is too thick. The diameter chosen for the prosthetic head was slightly smaller than the diameter of the native radial head, as judged on the basis of the fracture fragments.

Postoperative Management

The postoperative dressing incorporated a plaster splint that immobilized the elbow in 90° of flexion and neutral forearm rotation. Use of the splint was discontinued within two weeks (and usually within a few days) after the surgery, and active exercises of the elbow were initiated. Abduction of the shoulder was avoided in order to limit varus stress on the elbow.

Complications and Subsequent Surgical Procedures

Seven (26%) of the twenty-seven patients had one or more additional operations prior to the final evaluation. One patient with a terrible triad of injury in whom the coronoid fracture was not repaired had persistent elbow subluxation. This was treated with the application of a hinged external fixator during a second surgical procedure. This patient and three others had a subsequent operation to release a contracture at an average of eight months (range, six to eleven months) after the index surgery; all had associated heterotopic bone, and three had an associated ulnar neuropathy. It was suspected that the prosthesis was too proud or long in one of these four patients, and the prosthesis was removed; however, there was no capitellar wear or damage and no definitive evidence that the prosthesis was indeed too large. One of the patients who had a contracture release had a second contracture release, which was complicated by a deep infection. The infection was treated with removal of the prosthesis, serial débridements, and parenteral antibiotics. Two additional patients had a subsequent procedure to address ulnar nerve dysfunction that had developed nearly a year after the injury. One patient had removal of a misplaced screw that had been applied for fixation of the coronoid.

Evaluation

Twenty-seven patients returned for a research-specific evaluation, which was performed, after all subsequent operations had been done, by an author (J.N.D.) not involved in the patient's care. The evaluation consisted of an interview, a physical examination, radiographic examination, application of the MEPI¹⁹ and ASES²⁰, and administration of the DASH²¹. Pain was evaluated by summing the five pain ratings in the ASES, which are determined on a 10-point Likert scale. The sum of the scores ranges between 0, representing no pain, and 50 points, representing the worst pain ever experienced by the patient. The average duration of follow-up for all twenty-seven patients was forty months (range, twenty-four to fifty-five months) after the index radial head arthroplasty.

Radiographic signs of arthrosis were assessed according to the criteria of Broberg and Morrey²⁷. We defined radiolucency at the neck of the radius as discrete lucency around the majority of the prosthesis². We also recorded the presence or absence of heterotopic bone anterior to the radial neck and looked for any radiographic evidence of changes in the capitellum.

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Fig. 1:: This radiograph suggests that the prosthesis is oversized, resulting in substantial widening of the lateral part of the ulnohumeral joint and radiolucencies in the capitellum. However, the patient was doing very well clinically at three years and declined additional treatment. (Reprinted with permission of David Ring.)

Results

Materials and Methods | Results | Discussion | References

The final arc of ulnohumeral motion averaged 111° (range, 35° to 155°), with flexion averaging 131° (range, 95° to 155°) and an average flexion contracture of 20° (range, 0° to 60°). The final arc of forearm rotation averaged 130° (range, 0° to 180°), with pronation averaging 73° (range, 0° to 90°) and supination averaging 57° (range, 0° to 90°). None of the elbows had symptoms or signs of instability at the final evaluation. Two patients had persistent motor and sensory dysfunction of the ulnar nerve.

Seventeen (68%) of the twenty-five patients who retained the radial head prosthesis had radiographic evidence of lucency around the stem (Fig. 1). No patient had pain specifically referable to the radial head. According to the ASES Instrument, the seventeen patients with lucency around the stem of the prosthesis experienced somewhat less pain (average pain score, 8 points) than did the eight patients without lucency around the stem (average pain score, 11 points).

Twelve patients had radiographic signs of arthrosis, which was rated as Grade I in nine of them, Grade II in two, and Grade III in one according to the system of Broberg and Morrey²⁷. Three patients had a larger joint space on the lateral side of the ulnohumeral joint than on the medial side without other signs of an oversized radial head prosthesis such as angulation or narrowing of the medial joint space or capitellar changes reflecting increased pressure. One patient had radiographic changes consistent with a too large prosthesis (a particularly wide lateral joint space and capitellar radiolucency), but this patient was doing well and had no symptoms or interest in additional surgery (Fig. 1). Capitellar osteopenia was evident in nine other patients, none of whom were thought to have an oversized prosthesis (Fig. 2). Thirteen patients had heterotopic ossification anterior to the radial neck that did not restrict motion.

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This radiograph demonstrates the capitellar changes that can be observed even when there is confidence that the prosthesis is appropriately sized. (Reprinted with permission of David Ring.)

At the time of final follow-up, the average MEPI score was 85 points (range, 30 to 100 points) and, according to the MEPI categorical ratings, there were thirteen excellent results, nine good results, three fair results, and two poor results. The average score on the DASH was 17 points (range, 0 to 82 points), and the average score on the complete ASES Instrument was 84 points (range, 37 to 100 points).

Discussion

Materials and Methods | Results | Discussion | References

The radial head is no longer considered a surplus, or expendable, part of the skeleton⁴. It has been recognized as an important stabilizer of the elbow and forearm in both clinical and biomechanical studies^5,28-35.

Heim concluded that radial head resection is contraindicated on the basis of a study of 120 fractures of the radial head and the coronoid process of the ulna (the so-called terrible triad) in which premature arthrosis developed in eight of eleven patients treated with primary radial resection³⁶. Ring et al.³⁷, Broberg and Morrey³⁸, and Josefsson et al.³⁹ reported similar findings, including particular problems with persistent elbow instability and redislocation when the radial head had been discarded.

A recent report regarding the treatment of terrible triad injuries documented very few problems with persistent instability or recurrent dislocation when the radial head had been either repaired or replaced and other injured structures such as the coronoid and lateral collateral ligament had also been repaired⁴⁰. Unfortunately, it has also been recognized that operative repair of the radial head can be associated with early failure and later nonunion, particularly when there are more than three articular fragments⁴. The potential for early failure is particularly disconcerting when one is dealing with an injury with the potential for recurrent instability, such as the terrible triad lesion, but nonunion is also a concern with a forearm fracture-dislocation (the Essex-Lopresti pattern) as it is thought that the interosseous ligament may never heal properly and the radial head is essential to forearm stability.

Harrington et al.^29,41, Moro et al.², and Grewal et al.⁴² found that a metallic radial head contributed to the stability of the elbow and was useful in the treatment of traumatic elbow instability. All three of these groups documented the results of a prosthesis with a smooth neck that had been inserted loose intentionally (a metal spacer arthroplasty). The prosthesis that we describe differs from the implants used in those studies primarily because of its modularity and greater range of sizes. Our data confirm the findings in these four prior studies and support the idea that a radial head arthroplasty in which a metal spacer is intentionally inserted loose is a useful and important part of the treatment of an unstable elbow with a Mason Type-2 or 3 fracture of the radial head. The only patient who required a second operation for the treatment of instability was the one in whom the coronoid fracture had not been repaired very early in the series. We now routinely repair even small coronoid fractures, with sutures grasping the capsular attachment if the fragment is too small to accept drill-holes for direct suture repair.

The radial head prosthesis was intentionally inserted loose so that it would function as a spacer rather than as an integral part of the bone. The loose fit helps to accommodate the inevitable differences between the prosthetic and native radial heads. A bit of play allows accommodation of the prosthesis to various positions of the elbow and forearm. It is therefore not surprising that a substantial number of prostheses in this series showed radiographic evidence of looseness on follow-up radiographs. This was observed by Moro et al. as well². However, there were no symptoms or dysfunction that could be directly ascribed to the prosthesis in either series.

The major drawback of a metal radial head prosthesis is the possibility of insertion of a prosthesis that is too large⁴³— specifically, one that is too long. This has been referred to as "overstuffing" of the radiocapitellar joint, and it has been associated with radiocapitellar wear and erosions^9,44,45. It can also lead to subluxation and abnormal wear of the ulnohumeral joint, which is visible on an anteroposterior radiograph as a hinging open of the ulnohumeral joint on the lateral side and narrowing or angulation on the medial side^9,45. This is very uncommon when careful attention has been paid to sizing. It was suspected, but not definitely proved, that two patients in our series had an excessively large prosthesis. In addition to the technical details listed above, we recommend using the lateral edge of the coronoid process (at the junction with the lesser sigmoid notch that articulates with the radial head) as a guide to determining proper length. On the basis of a quantitative computed tomographic analysis of the normal intact radius and ulna, it appears that the radial head is an average of 1 mm prouder than this lateral edge⁴⁶. We recommend aiming for a match between the proximal articular surface of the radial head and the lateral edge of the coronoid at the junction with the lesser sigmoid notch, as a slightly short prosthesis is probably safer than a slightly long one. A prosthetic height of no more than 1 to 2 mm beyond the lateral edge of the coronoid process can be accepted, but more of the neck should be resected if the relative height of the radial head is greater than this. Modular implants may facilitate appropriate sizing.

Posttraumatic ulnar neuropathy is an increasingly recognized sequela of complex elbow trauma^47,48, particularly when there has been a careful evaluation by a hand surgeon who is sensitive to the occurrence of that complication. While it is unlikely that it is related directly to the radial head arthroplasty, the relative frequency of posttraumatic ulnar neuropathy with these injury patterns led us to consider prophylactic in situ release of the ulnar nerve in these patients.

Arthroplasty with an intentionally loosely placed metal spacer for the treatment of a severely fractured radial head helps to restore elbow stability and appears to cause problems only when it is too large. Minor radiolucencies around the neck of the prosthesis and mild radiographic changes in the capitellum are common but, to date, have not been associated with pain or elbow dysfunction. Longer-term follow-up is needed to fully understand the effect of the articulation of an appropriately sized metal prosthesis on the capitellar cartilage over time. ?

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Materials and Methods | Results | Discussion | References

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Topics

neck ; fracture ; elbow region ; metals ; prostheses and implants ; prosthesis implantation ; elbow instability ; spacer device ; radial head ; radial head arthroplasty

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Job N. Doornberg, Robert Parisien, P. Joppe van Duijn, David Ring; Radial Head Arthroplasty with a Modular Metal Spacer to Treat Acute Traumatic Elbow Instability. The Journal of Bone & Joint Surgery. 2007 May;89(5):1075-1080.

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