Radial head arthroplasty: A pillar of stability in complex elbow fractures

Table 1 Indications, advantages and disadvantages of surgical management options of radial head fractures

Surgical option	ORIF	RHA	RHR
Indications	Type II RHFs with mechanical block; and reconstructible type III and IV RHFs with simple fracture patterns	Unreconstructible RHFs, especially comminuted patterns; unreconstructible RHFs associated with ligamentous injury or elbow dislocation; instability following RHR; and failure of ORIF	Low-demand patients with stable elbows; salvage procedure following failed fixation or failed arthroplasty, in patients with stable elbow and low functional demand
Advantages	Restores native anatomy; and good for simple patterns	Good functional outcomes; maintains elbow stability; prevents proximal radial migration; and reduces early arthritis	Tolerated in low-demand patients despite mild instability
Limitations	Difficult in comminuted fractures; poorer outcomes in complex cases; and risk of nonunion and hardware failure	Complications are not rare; requires precise technique; small studies limit evidence; long-term data limited for young patients; and delayed RHA yields poorer outcomes	Alters elbow biomechanics; loss of RH’s stabilizing role, loss of support against valgus and axial forces; loss of PRUJ or DRUJ stability and proximal radial migration; and increases load on humero-ulnar joint, accelerate degenerative changes
Complication profiles	Nonunion; hardware failure; limited pronation/supination; and may require conversion to RHA	Painful loosening, radiolucency, overstuffing, osteoarthritis, HO, erosion, stiffness; PIN injury, dislocation, infection; reoperation rate: 12%-26%; and revision rate: 0%-45%	Early elbow instability; delayed: Cubitus valgus, proximal radial migration, arthritis, grip weakness, ulnar nerve irritation secondary to valgus overload or instability; and chronic elbow instability

ORIF: Open reduction and internal fixation; RHF: Radial head fracture; RHA: Radial head arthroplasty; RHR: Radial head resection; HO: Heterotopic ossification; PIN: Posterior interosseous nerve; PRUJ: Proximal radioulnar joint; DRUJ: Distal radioulnar joint.

Table 2 Comparative clinical outcomes and complication rates across radial head arthroplasty designs

Ref.	Implant comparison	Follow-up/ demographics	Clinical outcome	Complications
Rotini et al[78]	Bipolar vs monopolar cementless modular RHPs	Follow-up: 24 months; bipolar: n = 19, age: 42.4, M/F: 13/6; monopolar: n = 12, age: 47.5, M/F: 7/5	MEPS: Bipolar 90, monopolar 89.5; flexion: 131.5° vs 132.5°; extension: 16.8° vs 17.9°; pronation: 56.8° vs 70.4°; supination: 55.7° vs 75.4°	Bipolar: Arthrosis (n = 6), radiolucency (n = 7), HO (n = 9), resorption (n = 7); monopolar: Arthrosis (n = 6), radiolucency (n = 4), HO (n = 5), resorption (n = 2)
Gramlich et al[64]	Bipolar short-stem (22 mm) vs monopolar long-stem (50 mm) RHPs	Follow-up: 42.2 months; bipolar: n = 31, age: 37, M/F: 12/19; monopolar: n = 35, age: 48, M/F: 13/22	Not reported	Bipolar: Major complication required revision (22.6%), loosening (38.7%), prosthesis removal (n = 5); monopolar: Major complication required revision (17.1%), loosening (14.3%, P = 0.023), prosthesis removal (n = 1); the most frequent reason for revision was painful loosening: 9.1%, followed by arthrofibrosis (joint stiffness): 4.5%
Laumonerie et al[50]	Short stem (16 mm to 22 mm) vs long stem (30 mm) tight-fitting RHPs	Follow-up: 76.78 months; long-stem: n = 50, age: 52.2, M/F: 35/15; short-stem: n = 15, age: 53.3, M/F: 9/6	No significant difference between both groups; MEPS: Long-stem 86.8, short-stem 92; Quick-DASH: 17.7 vs 12.8; subjective elbow: 75.5% vs 80%; flexion: 133.6° vs 123°; extension: -16.8° vs -11°; supination: 66.3° vs 67.5°; pronation: 74.5° vs 81°	No significant difference between both groups; long-stem: Painful loosening (16%), osteolysis (46%), overstuffing (46%), capitellar wear (36%); short-stem: Painful loosening (40%), osteolysis (80%), overstuffing (47%), capitellar wear (64%)
Laflamme et al[65]	Smooth vs porous stemmed RHP	Follow-up: 6.3 years; porous stemmed: n = 36, age: 52.8, M/F: 19/17; smooth stemmed: n = 21, age: 45.6, M/F: 10/11	No significant difference between both groups; MEPS: Porous stemmed 96.5, smooth stemmed 97.1; VAS: 1.36 vs 0.67; extension improvement: 15° vs 12°; flexion improvement: 6° vs 1°; pronation improvement: 9° vs 5°; supination improvement: 15° vs 14°	No significant difference between both groups; porous stemmed: Osteolysis (n = 18), overstuffing (n = 4), HO (n = 13), reoperation (n = 2); smooth stemmed: Osteolysis (n = 5), overstuffing (n = 0), HO (n = 8)
Shimura et al[89]	Loose-fit vs press-fit stems in monopolar RHPs	Follow-up: 40.1 months; loose-fit: n = 17, age: 63, M/F: 5/12; press-fit: n = 15, age: 64, M/F: 4/11	Elbow flexion: Loose-fit 128°, press-fit 133°; extension: -12° vs -9°; pronation: 63° vs 78°; supination: 79° vs 83°	Loose-fit: Stiffness (n = 2), infection (n = 2), HO (n = 1), reoperation (n = 4); press-fit: Ulnar neuropathy (n = 1), painful loosening (n = 1), HO (n = 1), reoperation (n = 2)
Agyeman et al[72]	Cemented vs cementless RHPs	Follow-up; 45.2 months; cemented: n = 522, age: 49.3, M/F: 272/278; cementless: n = 356, age: 48.7, M/F: 189/34	No significant difference between both groups; MEPS: Cemented: 85.9 ± 6.1, cementless: 88.2 ± 3.4; flexion/extension: 119.1° ± 14.8° vs 115.8° ± 8.2°	Cemented: Complication rate (25.5%), implant loosening (8.6%), elbow stiffness/HO (8%), ulnar nerve palsy (4.3%); revision rate (7.9%); cementless: Complication rate (13.2%), elbow stiffness (9.8%), ulnar neuropathy (3.6%), loosening (2.1%), revision rate (3.1%)

RHP: Radial head prostheses; M/F: Male to female; MEPS: Mayo Elbow Performance Score; DASH: Disabilities of the Arm, Shoulder and Hand; VAS: Visual analogue scale; HO: Heterotopic ossification.