Radial head replacement best evidence

Radial Head Replacement BEST EVIDENCE

Hitesh GopalanClinical Asst Professor.

www.orthoevidence.comwww.orthopaedicprinciples.com

Radial HeadValgus stabiliser

Axial Stabiliser

60% of load transfer

ProblemsComminutionLUCL injuryMCL injuryElbow DislocationCoronoid fractureEssex Lopresti Injury(ALRUD)

Ligamentous Instability

Treatment OptionsConserveFixationExcisionPartial excisionReplacement

GuidelinesMason 1: Conservative

Mason 2: Fix

Mason 3 and 4: Fix with ligamentous repair, Replace or Partially Excise?

Ligamentous Instability

When ReplaceMason type 3 fractures

Associated ligamentous injuries(ALRUD)

Complex injury(Terrible triad)

Replace Vs FixationThree or more fragments

Impaction

Significant metaphyseal bone loss

Radial Head ExcisionChronic ulnar wrist pain, InstabilityElbow stiffness, Proximal radial migration 2-3

mmLoss of strength, Degenerative arthritisCubitus valgus, Heterotopic calcificationMyositis ossificans, Radial tunnel syndromeSynostosis, Ulnar neuropathy

Clin Orthop Relat Res. 1998; 353:40-52.

Radial Head Replacementmonoblock metalpress-fit and ingrowth stems,cemented stems, bipolar , and ceramicFloating Radial head prosthesis(Tornier, Fr)

Acrylic, silicone rubber, cobaltchromium Alloy, titanium

Osteochondral autografts(Han KJ 2012)

What’s the EvidenceLevel 4

Level 3

Level 2

No level 1 randomised trial that compares radial head replacement with fixation

Replacement –Level IVMoro et al.. El Sallakh S (J Orthop Trauma 2012)Shore et al(JBJS A-2008)

Excellent to Good Results in 80%

Less reports on complications like loosening, wear

Level 3Retrospective Case control designComplex InjuriesFixation (13)Vs Replacement(11)Outcomes: ASES , DASH scores

Better functional outcomes with Replacement

•Radial head replacement: 14 patients•Radial head repair: 8 cases•Level: IV•Outcome assessment: Broberg and Morrey scale•92. 9% satisfactory results in replacement group Vs 12.5 % satisfactory results in fixation group

Replacement: 22 patientsRepair: 23 patientsOutcomes: Broberg and Morrey SystemAnalysis: Satisfactory outcome in 91% in replacement group Vs 65% in ORIFLevel 2 Randomised Trial

Xiao Chen et al..Int Orthop 2011

ReplacementAccurate Sizing and length

Avoid overstuffing the joint

Damage to articular cartilage of capitellum

Level IV retrospective case series(n=32)MyoPC ProsthesisOutcomes: Broberg and Morrey, Mayo Elbow PerformanceSatisfactory Outcomes

Radial head FracturesUndisplaced(Mason 1): Conservative with

early mobilisation

Comminuted: Elderly- EXCISION

Radial HeadMason 2: one or two fragments, dense bone:

Fix

Mason 3-4: Replace

Thank You