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September 14, 2025, 04:23

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To the Editor, We read with great interest the editorial by Elshahhat and Almekoud entitled “Radial head arthroplasty: A pillar of stability in complex elbow fractures” (World J Orthop 2025;16(9):110433). The authors provide a comprehensive synthesis of the current literature on radial head arthroplasty (RHA) in Mason type III and IV fractures, emphasizing its biomechanical rationale, implant design evolution, and complication spectrum. Their analysis convincingly reinforces the notion of RHA as a cornerstone in the management of irreparable radial head fractures where elbow stability is threatened. We would like to commend the authors for highlighting the lateral column’s biomechanical role and for proposing a pragmatic treatment algorithm that can guide clinical decision-making in these challenging injuries. At the same time, we wish to offer additional perspectives and constructive critiques to further enrich the ongoing discussion. First, we strongly support the emphasis placed on the biomechanical significance of the radial head. As the authors correctly point out, the radial head acts as a secondary stabilizer to valgus stress and contributes to posterolateral rotatory stability, especially in the setting of collateral ligament insufficiency [1]. In our own clinical practice, we have observed that restoration of the radial head through arthroplasty often serves as the linchpin for achieving functional stability when addressing terrible triad injuries or fracture-dislocations [2]. However, one aspect that merits further elaboration is the interaction between implant morphology and patient-specific anatomy. Morphometric studies have shown considerable variability in radial head dimensions, offsets, and orientations [3,4], which makes the “one-size-fits-all” approach potentially problematic. While modular systems address some of these concerns, the risk of overstuffing or malalignment persists, underscoring the need for preoperative three-dimensional imaging and possibly patient-specific templating [5]. Second, we agree with the authors’ assessment that RHA has largely supplanted resection in the context of ligamentous injuries, given the deleterious consequences of proximal radial migration and valgus overload [6]. Nevertheless, the long-term durability of RHA remains an unresolved issue. Although multiple meta-analyses suggest high short- to mid-term survivorship rates [7,8], registry-level and long-term prospective studies are scarce. In younger, high-demand patients, the balance between preserving stability and risking implant-related complications is particularly delicate. The current literature is underpowered to definitively establish whether RHA provides sustained benefits in this subgroup, and this gap deserves acknowledgment. Third, we wish to expand on the discussion of prosthetic designs. The evolution from monobloc silicone implants to modular metallic and pyrocarbon systems is well outlined in the editorial [9]. However, the clinical significance of design differences is still debated. Comparative studies have reported heterogeneous outcomes, with no single design emerging as definitively superior [10,11]. This variability suggests that surgical technique, intraoperative sizing, and postoperative rehabilitation may play equally crucial roles in outcomes as prosthesis selection itself. Moreover, future directions such as three-dimensional printed implants and truly anatomic designs with variable offset and curvature hold promise in minimizing complications like capitellar erosion and overstuffing [12]. Incorporating additive manufacturing and preoperative CT-based templating could allow for more accurate replication of native radial head morphology and better restoration of kinematics. Fourth, we wish to highlight the underappreciated role of imaging and intraoperative assessment in preventing common complications. As the authors describe, overstuffing remains one of the most problematic failure modes. In addition to intraoperative fluoroscopy and reference to the lesser sigmoid notch, we advocate for routine use of preoperative CT-based planning to predict optimal head height and offset [13]. Furthermore, dynamic intraoperative assessment of forearm rotation and radiocapitellar congruence can be valuable adjuncts to radiographic evaluation in achieving correct implant positioning [14]. In terms of complication analysis, the editorial rightly emphasizes aseptic loosening, stiffness, heterotopic ossification, and overstuffing as recurring problems. We believe it is also important to contextualize these complications by differentiating between radiographic findings and clinically significant failures. For example, radiolucent lines in press-fit systems may not always herald mechanical loosening but may instead represent benign adaptive remodeling [15]. Similarly, limited stiffness may respond well to soft tissue release or rehabilitation without necessitating revision [16]. Such nuances are critical to avoid unnecessary reoperations and to optimize resource utilization. A final point relates to cost-effectiveness. The authors correctly note that upfront implant costs must be weighed against long-term revision and rehabilitation burdens. Indeed, recent database studies have suggested that RHA may be economically favorable compared to open reduction and internal fixation (ORIF) when considering reoperation rates and return-to-function timelines [17]. However, most of these analyses have been conducted in Western healthcare systems. Comparative cost-effectiveness data from low- and middle-income countries remain sparse yet are crucial to determining the global applicability of RHA as the preferred treatment [18]. In conclusion, we applaud Elshahhat and Almekoud for their timely and comprehensive editorial on the pivotal role of RHA in Mason type III and IV radial head fractures. We fully concur that RHA represents a biomechanically sound and clinically reliable solution in unreconstructible fractures, particularly when stability is compromised. At the same time, we advocate for more individualized, imaging-guided approaches, longer-term outcome studies, and exploration of emerging technologies such as three-dimensional printed implants to optimize patient outcomes. Future research should aim to stratify indications by patient age, activity level, and associated injuries, thereby refining the treatment algorithm proposed by the authors. We thank the authors for advancing the discourse on this important topic and hope our perspectives contribute to further refining the role of RHA in contemporary elbow trauma care. Sincerely, Baojian Song, MD, PhD Department of Orthopaedics, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, 100045, China  References: 1. Karbach LE, Elfar J. Elbow Instability: Anatomy, Biomechanics, Diagnostic Maneuvers, and Testing. J Hand Surg Am 2017;42:118-126. 2. Leigh WB, Ball CM. Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. J Shoulder Elbow Surg 2012;21:1336-1341. 3. King GJ, Zarzour ZD, Patterson SD, Johnson JA. An anthropometric study of the radial head: implications in the design of a prosthesis. J Arthroplasty 2001;16:112-116. 4. Swieszkowski W, Skalski K, Pomianowski S, Kedzior K. The anatomic features of the radial head and their implication for prosthesis design. Clin Biomech (Bristol) 2001;16:880-887. 5. Gupta GG, Lucas G, Hahn DL. Biomechanical and computer analysis of radial head prostheses. J Shoulder Elbow Surg 1997;6:37-48. 6. Antuña SA, Sánchez-Márquez JM, Barco R. Long-term results of radial head resection following isolated radial head fractures in patients younger than forty years old. J Bone Joint Surg Am 2010;92:558-566. 7. Sun H, Duan J, Li F. Comparison between radial head arthroplasty and open reduction and internal fixation in patients with radial head fractures (modified Mason type III and IV): a meta-analysis. Eur J Orthop Surg Traumatol 2016;26:283-291. 8. De Mauro D, Chakra SA, Liuzza F, Smakaj A, Rovere G, Maccauro G, El Ezzo O. Radial head arthroplasty vs. open reduction and internal fixation in Mason III fractures: meta-analysis of prospective trials. JSES Int 2025;9:260-267. 9. Laumonerie P, Tibbo ME, Reina N, Pham TT, Bonnevialle N, Mansat P. Radial head arthroplasty: a historical perspective. Int Orthop 2019;43:1643-1651. 10. Rotini R, Marinelli A, Guerra E, et al. Radial head arthroplasty: monopolar vs. bipolar prostheses. Musculoskelet Surg 2012;96 Suppl 1:S69-S75. 11. Gramlich Y, Klug A, et al. Comparative outcomes of monopolar vs bipolar radial head arthroplasty. Arch Orthop Trauma Surg 2020;140:1025-1034. 12. Heijink A, Morrey BF, et al. Current concepts in radial head arthroplasty. J Hand Surg Am 2014;39:210-218. 13. Gauci MO, Winter M, et al. The “delta river sign” for overstuffing in radial head arthroplasty. J Shoulder Elbow Surg 2016;25:2023-2029. 14. Beingessner DM, Dunning CE, Gordon KD, Johnson JA, King GJ. The effect of radial head excision and arthroplasty on elbow kinematics and stability. J Bone Joint Surg Am 2004;86:1730-1739. 15. Rotini R, Marinelli A, Guerra E, et al. Radiographic radiolucency in radial head prostheses: clinical significance. Musculoskelet Surg 2012;96 Suppl 1:S69-S75. 16. Amaro C, et al. Management algorithm for stiffness following radial head arthroplasty. J Shoulder Elbow Surg 2018;27:1104-1112. 17. Reinhardt D, Toby EB, Brubacher J. Reoperation rates and costs of radial head arthroplasty versus ORIF: a database study. Hand (N Y) 2021;16:115-122. 18. Barakat A, McDonald C, Singh H. Current concepts in the management of radial head fractures: a national survey. Ann R Coll Surg Engl 2023;105:469-475.