Purpose: Failure after radial head arthroplasty is uncommon, but clinically significant. Treatment for failure may involve implant removal. We describe fourteen patients who underwent implant removal after failed radial head arthroplasty. Methods: A retrospective review was performed to determine the cause of failure and clinical data were prospectively collected. Results: At mean follow up of 38 months the mean VAS for pain score was 3.0 and the mean DASH score was 40.5. The mean MEPS was 69. All patients demonstrated improved elbow range of motion. Mean elbow flexion at final follow up was 124 ° to an average extension deficit of 25 °. Fifty percent of patients exhibited clinical symptoms of cubital tunnel syndrome. Three patients required additional surgery after implant removal. Conclusions: Implant removal for failed radial head arthroplasty improves range of motion and demonstrates acceptable outcomes at intermediate-term follow up. However, 50% of patients developed cubital tunnel syndrome and 21% required revision surgery.
Radial head fractures are frequently the result of severe elbow trauma and may be associated with concomitant injury to the collateral ligaments and proximal ulna [
Radial head arthroplasty is commonly performed acutely as a treatment for radial head fractures that are not amenable to reconstruction in order to re-es- tablish elbow stability and allow early motion after injury [
Complications specific to metallic radial head arthroplasty include stem loosening and capitellar erosion/osteopenia [
Following Institutional Review Board (IRB) approval at our institution, a Current Procedure Terminology search was performed using the code 24,164 (implant removal, radial head). Patients who underwent a removal of radial head arthroplasty from January 1, 1995 through December 31, 2014 were identified. Inclusion criteria were any patient who underwent removal of radial head arthroplasty and was >18 years old. Patients who underwent revision radial head arthroplasty (i.e., replacement after removal) or who had follow up of less than 3 months were excluded. Twenty patients were initially identified. Two patients elected not to participate, and an additional 4 patients did not meet the follow-up requirement. Therefore, 14 patients were available for our study. All patients were enrolled either by providing written informed consent or under an approved enrollment waiver granted by the IRB.
The mean follow up was 38 months (3 - 107). Ten females and 4 males were included, with an average age of 51 (22 - 82) at the time of implant removal. Two of the radial head implants were silastic, and the remaining 12 were metal. The original diagnoses leading to radial head replacement are listed in
Diagnosis | Number (n) |
---|---|
Monteggia Fracture/Dislocation | 7% |
Post-Traumatic Arthritis | 14% |
Essex-Lopresti Injury | 14% |
Isolated Radial Head Fracture | 22% |
Terrible Triad Injury | 43% |
Patient history and details regarding radial head implant removal were obtained via the electronic medical record. Seven patients underwent isolated radial head arthroplasty. The remaining 7 underwent additional procedures for associated injuries at the time of initial arthroplasty, the details of which are listed in
The average time from radial head arthroplasty to subsequent removal was 54 months (6 - 376). Three patients underwent implant removal more than 36 months from the time of arthroplasty (61, 120, 376). Six patients underwent removal less than 12 months from their initial arthroplasty. Four patients underwent a total of eight additional operations between the initial radial head arthroplasty and eventual implant removal. The indications for radial head implant removal are listed in
Clinical outcome scores including a 10-point visual analog scale for pain (VAS), Mayo Elbow Performance Scores (MEPS), and Disabilities of the Arm, Shoulder, and Hand (DASH) were acquired in person or via telephone interview [
A goniometer was used to measure elbow range of motion. Grip strength was assessed for both the injured and contralateral extremity using a hand-held dynamometer (TBS 2000 Functional Testing Systems Software, Quest Medical Group, Inc., West Jordan, Utah), and measurements were adjusted based on hand dominance. Flexion and extension of the elbow was measured with the forearm in neutral rotation and pronation and supination was measured with the elbow at 90° of flexion with the patient holding a dowel. Elbow radiographs were reviewed and degenerative changes were analyzed according to the Broberg and Morrey classification grade 0 (normal joint), grade I (slight joint-space narrowing with minimum osteophyte formation), grade II (moderate joint-space nar-
NUMBER | Age at DOS | Diagnosis (Primary) | Procedure (Primary) | Interval Surgeries | Diagnosis (Revision) | Procedure (Revision) | VAS | MEPS | DASH | Complications | Return to OR (Dx) | Return to OR (Procedure) | Notes | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 26 | Radial Head Fracture | Radial Head Replacement (Silastic) | Implant Failure (Fracture) | Removal of Implant | Ulnar parasthesias | ||||||||
2 | 43 | Radial Head Fracture Ulna Fracture (Monteggia) | Radial Head Replacement Ulna ORIF | Heterotopic Ossification Radioulnar Synostosis | Removal of Implant Removal of Radioulnar Synostosis | Longitudinal Instability/ ulnar positive | ||||||||
3 | 62 | Radial Head Fracture/ Dislocation (Terrible Triad) | Radial Head Replacement | Aseptic Loosening | Removal of Implant | 0 | 100 | 5 | No laxity, asymptomatic | |||||
4 | 82 | Radial Head Fracture/ Dislocation (Terrible Triad) | Radial Head Replacement LCL Repair | 1) Heterotopic Ossification Resection Ulnar Nerve Transposition 2) Irrigation/ Debridement of Deep Infection | Infection | Removal of Implant Irrigation and Debridement | ||||||||
5 | 47 | Radial Head Fracture/ Dislocation (Terrible Triad) | Radial Head Replacement LCL Repair | Elbow Contracture Cubital Tunnel Syndrome | Removal of Implant Contracture Release Ulnar Nerve Release in situ | 1 | 75 | 60 | Narcotic use Ulnar paras thesias | |||||
6 | 48 | Radial Head Fracture/ Dislocation (Terrible Triad) | Radial Head Replacement Coronoid Fracture ORIF LCL Repair | 1) External Fixator Placement Coronoid ORIF MCL Repair 2) Trans Articular Pinning 3) Removal of Implant Removal of External Fixator | Elbow Contracture | Removal of Implant | 5 | 50 | 39.2 | Narcotic use Ulnar parasthesias | ||||
7 | 59 | Radial Head Fracture/ Dislocation (Terrible Triad) | Radial Head Replacement LCL Repair M CL Repair | Elbow Contracture Cubital Tunnel Syndrome Adhesive Capsulitis (Shoulder) | Removal of Implant Ulnar Nerve Release in situ Manipulation under Anesthesia (Elbow) Manipulation under Anesthesia (Shoulder) | Ulnar parasthesias | ||||||||
8 | 71 | Radial Head Fracture | Radial Head Replacement | Elbow Contracture Overstuffed Implant | Removal of Implant | 0 | 100 | 0 | No complaints Mild objective valgus laxity |
9 | 54 | Post-Traumatic Arthritis* | Radial Head Replacement | Elbow Contracture Post Traumatic Arthritis | Removal of Implant Open Debridement Capsular Release | 4 | 65 | 60 | Return to OR | Proximal Radioulnar Joint Pain Posterior Interossesous Nerve Syndrome | Allograft PRUJ Interposition Posterior Interosseous Nerve Release | Narcotic use Ulnar parasthesias (s/p release) Requires brace, minimal use of extremity | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
10 | 55 | Radial Head Fracture Essex Lopresti Injury | Radial Head Replacement Contracture Release | Painful Elbow Capitellar Arthritis | Removal of Implant Open Debridement | 1 | 75 | 32.5 | Subjective weakness Subjective instability, pain with work (manual labor) | ||||
11 | 31 | Radial Head Fracture Essex Lopresti Injury | Radial Head Replacement | 1) Lateral Column Procedure 2) Capsular Release Heterotopic Ossification Excision | Heterotopic Ossification Elbow Contracture | Removal of Implant Heterotopic Ossification Excision Capsular Release | 8 | 60 | 55 | Return to OR | DRUJ/ Longitudinal Instability Ulnar Positive Variance | DRUJ Reconstruction IO Membrane Reconstruction Ulnar Shortening Osteotomy | Ulnar parasthesias |
12 | 56 | Radial Head Fracture | Radial Head Replacement (Silastic) | Implant Failure (Fracture) Cubital Tunnel Syndrome | Removal of Implant Cubital Tunnel Release in Situ | 0 | 75 | 25 | Moderate difficulty with playing piano | ||||
13 | 22 | Post Traumatic Arthritis* | Radial Head Replacement | Aseptic Loosening Implant Subluxation | Removal of Implant | 5 | 60 | 41.7 | Return to OR | Cubital Tunnel Syndrome | Cubital Tunnel Release in Situ | Subjective instability Minimal use of extremity | |
14 | 57 | Radial Head Fracture/ Dislocation (Terrible Triad) | Radial Head Replacement Coronoid ORIF LCL Repair Ulnar Nerve Transposition External Fixator Placement | Removal of External Fixator Examination under Anesthesia Irrigation and Debridement (Pin Sites) | Aseptic Loosening | Removal of Implant | 7 | 30 | 86.7 | Ulnar parasthesias Minimal use of extremity Post traumatic arthritis, scheduled for TEA |
Diagnosis | Number (n) |
---|---|
Radio-Ulnar Synostosis | 7% |
Infection | 7% |
Capitellar Arthritis | 7% |
Implant Fracture (Silastic) | 14% |
Aseptic Loosening | 22% |
Elbow Contracture | 43% |
rowing with moderate osteophyte formation), or grade III (severe degenerative changes with gross destruction of the joint) [
The mean VAS score for pain was 3.0 (0 - 7.6) and the mean DASH score was 40.5 (0 - 86.7). The mean MEPS score was 69 (30 - 100); and based on the MEPS scale two patients had excellent results, three had good results, three had fair results, and two had poor results. All patients demonstrated some improvement in elbow range of motion after radial head implant removal. Mean flexion of the elbow at final follow up was 124˚ to an extension deficit of 25˚. Pronation of the forearm averaged 72˚ and supination averaged 64˚. Compared to preoperative assessment, there were improvements in flexion (11˚), extension (15˚), pronation (8˚), and supination (11˚). Mean grip strength was 29.8 lbs., which repre- sented a 31.2% deficit compared to the contralateral side when adjusted for hand dominance. The radiographic grade of elbow degeneration based on the Broberg and Morrey classification is shown in
Seven of the 14 patients (50%) complained of paresthesias in the distribution of the ulnar nerve consistent with cubital tunnel syndrome, two of which had previously undergone in situ release at the time of radial head implant removal. One additional patient underwent subsequent ulnar nerve release in situ as a secondary surgery after implant removal. Three patients remained on narcotic medication attributed to their elbow pain, and two patients noted subjective valgus instability of the elbow.
Three patients underwent revision surgery after radial head implant removal during the study period. Patient 9 underwent radial head arthroplasty for post- traumatic arthritis after multiple prior attempts at surgical reconstruction. The patient developed pain and contracture soon after arthroplasty and then subsequently underwent implant removal and contracture release approximately 6 months later. The patient then developed symptoms of proximal radio-ulnar joint impingement and posterior interosseous nerve (PIN) syndrome after implant removal. A proximal radio-ulnar joint reconstruction with allograft interposition and PIN release was performed. At the time of final follow up, the patient had a VAS for pain score of 4, DASH of 60, and fair outcome according to the MEPS scale (65).
Patient 11 suffered an Essex-Lopresti-type injury and underwent radial head arthroplasty as part of the initial surgical treatment. Prior to implant removal, a lateral column procedure and removal of heterotopic ossification was performed
Grade | Number (n) |
---|---|
O | 7% |
I | 58% |
II | 14% |
III | 7% |
N/A | 14% |
due to persistent contracture. The radial head implant was then removed approximately 2 years after initial placement. Within 7 months, the patient demonstrated symptoms of longitudinal forearm instability and ulnar positive variance (
Patient 9 was a 61-year-old female who sustained a comminuted radial head fracture and elbow dislocation. She was treated with open reduction radial head replacement and ulnar-lateral collateral ligament repair. The radial head subsequently loosened, causing mechanical symptoms and limited range of motion (
Patient 13 required radial head arthroplasty for post-traumatic arthritis after multiple prior attempts at surgical reconstruction. The patient demonstrated signs of implant loosening associated with pain and therefore underwent radial head implant removal. Approximately 18 months later, the patient required ulnar nerve release in situ for persistent complaints of cubital tunnel syndrome. This patient also demonstrated outcome scores below the series average: VAS score of 5, DASH score of 42, and MEPS of 60.
One additional patient underwent radial head implant removal secondary to loosening after arthroplasty due to terrible triad elbow fracture/dislocation. This patient had the poorest outcomes of all patients in the series with a VAS score of 6.7, a DASH score of 87, and an MEPS of 30, all consistent with significant pain and disability. Because of the development of post-traumatic arthritis the patient was scheduled for a total elbow arthroplasty at the time of final follow up for this study.
To our knowledge, this study is the first to describe the outcome of patients undergoing implant removal after failed radial head arthroplasty. In a small number of patients, we have demonstrated acceptable outcomes in the majority of patients. Several of the patients in this series reported minimal pain and dysfunction, while several others demonstrated continued significant disability. All patients attained improvement in elbow range of motion after radial head implant removal, and the average flexion to extension deficit (124˚ - 25˚) attained closely corresponds to the accepted 100˚ functional arc of motion from 30˚ - 100˚ of flexion [
Three patients required revision surgery after radial head implant removal, and a fourth patient remained severely disabled and was scheduled to undergo total elbow arthroplasty at the conclusion of the study. Each of these patients had undergone multiple surgical procedures prior to radial head implant removal, likely indicative of significant underlying disability and more severe elbow injury. Additionally, two patients in this study underwent radial head replacement for post-traumatic arthritis, and both of these patients are included in the above-noted failures. Two of the patients in this study underwent radial head arthroplasty due to an Essex-Lopresti injury. Both of these patients also required revision surgery after implant removal consistent with the severe nature of the original injury. One of these patients developed longitudinal instability of the forearm after implant removal, which is suggestive of underlying instability that had been masked by the radial head arthroplasty.
Of note, a high percentage of the patients in the study demonstrated symptoms consistent with cubital tunnel syndrome. We believe this is likely related to persistent valgus instability of the elbow, which may be imperceptible to the patient and rarely led to frank symptomatic instability of the elbow but was significant enough to irritate the ulnar nerve.
While no previous studies have described outcomes after removal of failed radial head arthroplasty, short-to intermediate-term follow up after arthroplasty for radial head fracture has generally demonstrated favorable results [
Removal of a radial head implant may be compared to radial head excision for primary and delayed treatment for radial head fractures. Multiple studies have demonstrated excellent long-term results after radial head excision [
One of the main limitations of this study is that a single cohort of patients was available for review with no control or comparative group. In addition, we reviewed a heterogeneous group of patients who underwent radial head arthroplasty for a variety of both acute and chronic elbow pathology. However, the strength of the study lies in the fact that this group of patients had not previously been described in the literature.
In this study, the majority of patients demonstrated fair to good outcomes after removal of failed radial head arthoplasty. All patients attained improved range of motion. A high percentage of patients exhibited persistent signs of cubital tunnel syndrome, and one of our patients developed longitudinal instability of the forearm after implant removal. Though limited by the number of patients in this study, worse outcomes were demonstrated in patients undergoing implant removal after radial head arthroplasty for post-traumatic arthritis or Essex-Lopresti injury.
In conclusion, implant removal is a viable treatment option for failed radial head arthroplasty. We advise giving strong consideration to ulnar nerve release with transposition after radial head implant removal. In addition, intraoperative assessment of longitudinal stability after implant removal is imperative and should be corrected as indicated.
Holt, D.C., Struk, A.M., King, J.J., Matthias, R.C. and Wright, T.W. (2017) Clinical Outcome for Failed Radial Head Arthroplasty Treated with Ex- plantation. Open Journal of Orthopedics, 7, 199-210. https://doi.org/10.4236/ojo.2017.78022