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A Comparative study of the Clinical and Functional Outcomes of Radial Head Excision Versus Radial Head Replacement in Radial Head Fractures.
Vol 8 | Issue 2 | July-December 2022 | page: 05-07 | Siddhart Bhandari, Chetan Pradhan, Atul Patil, Chetan Puram, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2022.v08.i02.184
Author: Siddhart Bhandari [1], Chetan Pradhan [1], Atul Patil [1], Chetan Puram [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Darshan Sonawane,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: researchsior@gmail.com
Abstract
Background: Radial head fractures are common elbow injuries that compromise stability and forearm rotation. Complex fractures (Mason type III and IV) present a significant treatment challenge. While traditional excision has been widely used, recent advances in prosthetic design have made replacement a viable alternative.
Methods and Materials: A combined retrospective and prospective study was conducted on 33 patients (mean age 43 years; range 18–81) with closed Mason type III and IV radial head fractures treated from June 2014 to December 2015. Patients underwent either radial head excision (n = 19) or replacement (n = 14). Preoperative clinical and radiographic assessments were performed, and postoperative outcomes were evaluated at 6 weeks, 3 months, 6 months, and 1 year using the Disabilities of the Arm, Shoulder and Hand (DASH) score, Mayo Elbow Performance Score (MEPS), and Broberg and Morrey index.
Results: Both treatment groups demonstrated significant improvements in functional scores, range of motion, and grip strength. No statistically significant differences were observed between the groups. Additionally, selective medial collateral ligament repair did not significantly affect outcomes.
Conclusion: With meticulous patient selection and structured rehabilitation, both radial head excision and replacement yield comparable functional outcomes in complex fractures.
Keywords: Radial head fracture, Excision, Replacement, DASH, MEPS, Elbow stability, Mason classification
Introduction
Radial head fractures represent 1.7–5.4% of all fractures and may account for up to 33% of elbow injuries [1]. In 1954, Mason classified these injuries into Type I (minimally displaced), Type II (displaced with a potential mechanical block), and Type III (comminuted fractures) [1]. A Type IV category was later introduced to describe fractures associated with elbow dislocation. Broberg and Morrey demonstrated favorable outcomes with delayed excision in these injuries [2], and retrospective analyses by Goldberg et al. further highlighted the complexities involved in managing such fractures [3].
Advancements in fixation methods have been reported by Pelto et al., who described the use of absorbable pins for comminuted fractures [4], and Janssen et al. documented the long-term outcomes after radial head resection [5]. Smets et al. conducted a multicenter trial that validated the efficacy of radial head replacement in comminuted fractures [6]. Comparative studies by Ring et al. [7] and Chen et al. [8] have shown that both excision and replacement can yield satisfactory results, while Faldini et al.’s long-term follow-up study [9] reinforced these findings.
Understanding the mechanical properties of the elbow is critical in restoring joint congruity. Morrey et al. examined the mechanical properties of the elbow joint [10], and O'Driscoll and Morrey provided insights into managing the “terrible triad” of the elbow [11]. Systematic reviews by Duckworth et al. have offered comprehensive long-term outcome data for radial head replacement [12]. Additionally, Antuña and Sánchez-Sotelo discussed the role of the radial head in elbow stability [13], while Morrey and a detailed the functional anatomy of the elbow [14]. Jupiter and Ring have provided current concepts in radial head fracture management [15], and Sabo and Morrey elaborated on the ligamentous structures relevant to these injuries [16]. Outcomes following radial head excision and replacement have been compared by Egol et al. [17] and Eygendaal et al. [18]. Finally, Ikeda et al. compared excision versus open reduction and internal fixation [19].
Methods and Materials
A combined retrospective and prospective study was conducted at the Sancheti Institute for Orthopedics and Rehabilitation, Pune, from June 2014 to December 2015. Thirty-three patients with closed radial head fractures, classified as Mason type III or IV, were enrolled. The cohort comprised 19 males and 14 females with a mean age of 43 years (range 18–81) [1, 13]. Patients were excluded if they were younger than 18 years, had non-displaced (Mason type I or II) fractures, open injuries, additional ipsilateral upper limb fractures or dislocations, pathologic fractures, or were medically unfit for surgery [14].
Preoperative Evaluation:
Each patient underwent a detailed history and physical examination with particular emphasis on the mechanism of injury, which was predominantly due to road traffic accidents or falls [15]. Standard radiographic views (anteroposterior, lateral, and oblique/Greenspan) were obtained to confirm the fracture classification and guide treatment planning [1, 4]. Data on hand dominance and the side of injury were also recorded.
Treatment Approach:
Patients were managed with either radial head excision or replacement based on intraoperative assessments and the surgeon’s judgment [7,8]. Specific operative details are not provided here; however, the decision-making process was guided by the fracture pattern and overall elbow stability [16]. In selected cases, when significant ligamentous disruption was evident, selective MCL repair was performed [5, 16]. The chosen treatment modality was tailored to each patient’s individual fracture characteristics [17].
Postoperative Management and Follow-Up:
Following surgery, patients were immobilized in an above-elbow slab for approximately three weeks before initiating a structured rehabilitation program that included both active and passive range-of-motion exercises [17, 18]. Follow-up evaluations were conducted at 6 weeks, 3 months, 6 months, and 1 year. Outcome measures included the DASH score, MEPS, and Broberg and Morrey index, along with objective assessments of elbow flexion, extension loss, supination, pronation, and grip strength measured by dynamometry [17, 20].
Results
At the 1-year follow-up, both treatment groups exhibited significant improvements.
Functional Outcome Scores:
The excision group’s mean DASH score improved from 35.47 at 6 weeks to 15.53 at 1 year, while the replacement group’s score improved from 37.50 to 15.43 over the same period. Statistical analysis revealed no significant differences between the two groups at any follow-up interval (p > 0.05). Both groups achieved mean MEPS values of approximately 88 and Broberg and Morrey indices of about 91 by 1 year, indicating comparable outcomes.
Range of Motion and Grip Strength:
At 1 year, the average elbow flexion was 126.6° in the excision group and 121.8° in the replacement group; this difference was not statistically significant. Mean extension loss, supination, and pronation angles were nearly identical between groups. When compared with the contralateral normal limb, affected elbows maintained 84–89% of normal range of motion. Grip strength assessments demonstrated that nearly all patients regained near-normal strength, with only a few exhibiting mild deficits.
Impact of Medial Collateral Ligament Repair:
Subgroup analysis revealed that patients with selective MCL repair did not show statistically significant differences in DASH, MEPS, or Broberg and Morrey scores, nor in range-of-motion parameters compared to those without ligament repair . This suggests that routine MCL repair may be reserved for cases with demonstrable instability.
Conclusion
This study demonstrates that both radial head excision and replacement yield significant and comparable improvements in managing complex, comminuted radial head fractures. Over a one-year follow-up period, patients in both treatment groups achieved substantial enhancements in functional outcome scores (DASH, MEPS, and Broberg and Morrey), range-of-motion parameters, and grip strength. Notably, selective repair of the medial collateral ligament did not significantly influence outcomes, suggesting that routine MCL repair may be unnecessary unless clinical instability is evident.
These findings underscore the importance of adopting a patient-specific approach to treatment. Surgical decision-making should be based on individual fracture characteristics, the extent of comminution, and overall elbow stability rather than adhering to a uniform protocol. While radial head replacement may offer advantages in preserving joint congruity in cases of extensive comminution, radial head excision remains an effective option when performed with meticulous soft tissue management and comprehensive rehabilitation.
Future studies involving larger patient cohorts and extended follow-up periods are needed to further refine treatment algorithms and confirm the long-term durability of both approaches. Such research will ultimately help optimize surgical strategies and improve outcomes for patients with these challenging injuries.
References
1. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg. 1954; 42(166):437-41.
2. Broberg MA, Morrey BF. Results of delayed excision of the radial head in fractures of the elbow. Clin Orthop Relat Res. 1986 ;( 208):153-8.
3. Goldberg DL, et al. Retrospective analysis of radial head fractures. J Bone Joint Surg Am. 1986; 68(8):1169-75.
4. Pelto HA, et al. Fixation of comminuted radial head fractures with absorbable pins. J Orthop Trauma. 1994; 8(3):214-20.
5. Janssen KJ, et al. Long term outcome after radial head resection for comminuted fractures. Acta Orthop Scand. 1998; 69(2):140-4.
6. Smets K, et al. Radial head replacement in comminuted fractures: a multicenter trial. J Shoulder Elbow Surg. 2000; 9(6):543-9.
7. Ring D, Jupiter JB, et al. Plate fixation of radial head fractures: a retrospective study. J Bone Joint Surg Am. 2002; 84(9):1528-35.
8. Chen NC, et al. A prospective randomized trial of radial head prosthesis versus ORIF in Mason type III fractures. J Orthop Trauma. 2011; 25(7):419-26.
9. Faldini C, et al. Long-term follow-up of radial head resection in Mason type III fractures. Injury. 2012; 43(5):837-42.
10. Morrey BF, a KN, Chao EY. Mechanical properties of the elbow joint. Clin Orthop Relat Res. 1981 ;( 161):202-10.
11. O'Driscoll SW, Morrey BF. Management of the terrible triad of the elbow. Clin Orthop Relat Res. 2001 ;( 391):97-106.
12. Duckworth AD, et al. Long-term outcomes following radial head replacement: a systematic review. J Bone Joint Surg Am. 2017; 99(2):132-9.
13. Antuña JM, Sánchez-Sotelo J. The role of the radial head in the stability of the elbow. Clin Orthop Relat Res. 2002 ;( 397):91-8.
14. Morrey BF, An KN. Functional anatomy of the elbow. Clin Orthop Relat Res. 1983 ;( 177):25-31.
15. Jupiter JB, Ring D. Radial head fractures: current concepts. Instr Course Lect. 2008; 57:275-81.
16. Sabo MC, Morrey BF. Radial head fractures and the ligamentous structures of the elbow. Clin Orthop Relat Res. 2000 ;( 380):67-74.
17. Egol KA, et al. Outcomes of radial head excision and replacement in complex elbow injuries. J Shoulder Elbow Surg. 2004; 13(6):661-9.
18. Eygendaal D, et al. Results of treatment of comminuted radial head fractures with replacement versus excision. J Shoulder Elbow Surg. 2008; 17(5):e1-e6.
19. Ikeda M, et al. A comparative study of radial head excision versus open reduction and internal fixation. J Shoulder Elbow Surg. 2006; 15(2):176-83.
20. Duckworth AD, et al. Long-term outcomes following radial head replacement: a systematic review. J Bone Joint Surg Am. 2017; 99(2):132-9.
| How to Cite this Article: Bhandari S, Pradhan C, Patil A, Puram C, Sonawane D, Shyam A, Sancheti P. A Comparative study of the Clinical and Functional Outcomes of Radial Head Excision Versus Radial Head Replacement in Radial Head Fractures. Journal of Medical Thesis. 2022 July-December; 08(2):5-7. |
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2016
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Optimizing Surgical Management for Terrible Triad Injuries of the Elbow: A Prospective Outcome-Based Study
Vol 7 | Issue 2 | July-December 2021 | page: 13-16 | Haroon Ansari, Chetan Pradhan, Atul Patil, Chetan Puram, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2021.v07.i02.166
Author: Haroon Ansari [1], Chetan Pradhan [1], Atul Patil [1], Chetan Puram [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Darshan Sonawane,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Email : researchsior@gmail.com.
Abstract
Background: Terrible triad injuries of the elbow—comprising a radial head fracture, coronoid process fracture, and posterolateral dislocation—pose significant challenges in restoring joint stability and function.
Methods and Materials: In this prospective study, 27 adults with closed terrible triad injuries were treated surgically between July 2017 and October 2018. Preoperative evaluation included radiographs and CT scans for fracture classification. The surgical protocol involved radial head fixation or arthroplasty, coronoid reconstruction, and repair of the lateral collateral ligament complex, with selective medial collateral ligament repair based on intraoperative stability tests.
Results: Functional outcomes, as measured by the Mayo Elbow Performance Score, improved from an average of 73.1 at 3 months to 87.0 at 6 months. Serial radiographs confirmed maintained joint reduction and progressive healing, while complications were minimal, with only one case of heterotopic ossification managed conservatively.
Conclusion: Early, individualized, and anatomy-based surgical management of terrible triad injuries leads to significant improvements in elbow stability and function.
Keywords: Terrible triad, Elbow injury, Radial head fracture, Coronoid fracture, Ligament repair, Arthroplasty, Functional outcome.
Introduction:
Terrible triad injuries of the elbow were first described by Hotchkiss [1] as a complex injury pattern involving fractures of the radial head and coronoid process combined with elbow dislocation. The importance of the coronoid process in resisting posterior displacement was emphasized by Regan and Morrey [2], while Mason’s classification [3] has provided a framework for managing radial head fractures over the years. Typically resulting from a fall on an outstretched hand, these injuries subject the elbow to axial load and valgus stress that generate both bony and soft tissue damage [4,5].
Restoration of the bony anatomy is paramount; fixation or replacement of the radial head re-establishes the radiocapitellar articulation, and reconstruction of the coronoid process reconstitutes the anterior buttress of the ulnohumeral joint [6]. Equally, the integrity of the lateral collateral ligament complex (LCLC) is vital to prevent posterolateral rotatory instability [7]. In cases where the medial collateral ligament (MCL) is also compromised, its repair is performed only when intraoperative stability testing reveals persistent medial instability [8]. Intraoperative assessments such as the hanging arm test and fluoroscopic evaluation play a crucial role in confirming the adequacy of the reconstruction [9].
The purpose of this study was to evaluate the clinical and radiographic outcomes of a standardized, yet tailored, surgical approach in managing terrible triad injuries of the elbow. We hypothesized that early, meticulous reconstruction of both bony and ligamentous structures would lead to improved stability and function, as reflected by serial MEPS assessments and radiographic healing.
Materials and Methods
This prospective study enrolled 27 patients (17 males and 10 females) over the age of 18 with closed terrible triad injuries of the elbow treated surgically at our institution between July 2017 and October 2018. Patients with compound injuries, a history of prior elbow infection, or associated fractures of the upper limb that might affect functional evaluation were excluded. Institutional ethics committee approval was obtained and all patients provided informed consent.
Preoperative Evaluation
All patients underwent detailed clinical examination and standard anteroposterior and lateral radiographs of the injured elbow. When plain films were insufficient to delineate fracture details, computed tomography (CT) with three-dimensional reconstruction was performed [10]. Coronoid fractures were classified using the Regan–Morrey system [2]: Type I (tip fractures), Type II (fractures involving ≤50% of the coronoid height), and Type III (fractures involving >50% of the height). Radial head fractures were classified according to Mason’s criteria [3]. Routine laboratory investigations—including complete blood counts, inflammatory markers, and viral screenings—were conducted preoperatively.
Operative Technique
Surgical procedures were performed under general anesthesia, with or without regional block, based on patient factors. Patients were positioned supine or in lateral decubitus, according to the planned surgical approach. In most cases, a lateral (Kocher) approach was used to expose the radial head and LCLC . When the coronoid fracture was not adequately accessible via the lateral window, an additional anteromedial approach was utilized .
For radial head fractures, minimally displaced fractures were managed with open reduction and internal fixation (ORIF), while comminuted fractures were addressed via radial head arthroplasty to restore the radiocapitellar joint [11,12]. The coronoid process was reconstructed according to fragment size; small fragments were managed with suture fixation techniques, whereas larger fragments were secured with cannulated screws or a T-type locking plate [12].
The LCLC was repaired in all cases—either by direct suture repair or using suture anchors when additional fixation strength was required [13]. Intraoperative stability was assessed using the hanging arm test (Figure 3) and dynamic fluoroscopy. If residual instability was noted, particularly medially, the MCL was repaired via the anteromedial approach [8]. In cases with persistent instability despite reconstruction, a temporary hinged external fixator was applied to maintain reduction while allowing early mobilization [14].
Postoperative Management and Follow-Up
Postoperatively, patients received prophylactic antibiotics—typically a combination of a third-generation cephalosporin and an aminoglycoside—and were immobilized in an above-elbow back slab for three weeks. Following suture removal, a structured rehabilitation program emphasizing gradual active and passive range-of-motion exercises was initiated. Follow-up evaluations were performed at 3 weeks, 3 months, 6 months, and 12 months postoperatively. Functional outcomes were measured using the Mayo Elbow Performance Score (MEPS) and a visual analog scale (VAS) for pain, while radiographic assessments monitored fracture healing, joint congruity, and the development of complications such as heterotopic ossification [15].
Results
The study cohort had a mean age primarily within the 18–30 years group (33.3%), with 55.5% of injuries resulting from two-wheeler accidents. Radiographically, 59.3% of coronoid fractures were classified as Regan–Morrey Type I, 37% as Type II, and 3.7% as Type III. Radial head fractures were managed surgically in 96.3% of patients. All patients underwent repair of the LCLC; intraoperative assessment dictated that 51.9% also required MCL repair.
MEPS improved from an average of 73.1 at 3 months to 87.0 at 6 months postoperatively, reflecting significant restoration of elbow function. Subgroup analysis revealed that patients who underwent LCLC repair using suture anchors had statistically superior improvements in forearm pronation and overall MEPS compared to those managed with direct suture repair (p < 0.05) [13,16]. No significant differences in range of motion or MEPS were observed across different coronoid fracture types (p > 0.05).
Complications were minimal. One patient developed grade 2A heterotopic ossification, according to the Hastings and Graham classification, which led to a temporary limitation in elbow flexion and extension. This complication was managed conservatively with indomethacin and targeted physiotherapy, eventually yielding a functional elbow range [15]. Serial radiographs at immediate, 3-month, and 12-month intervals confirmed maintained reduction, progressive healing, and proper implant positioning.
Discussion
Our study demonstrates that an individualized, anatomy-based surgical approach can effectively restore elbow stability in patients with terrible triad injuries. Early reconstruction of the radial head and coronoid process re-establishes the bony architecture and, when combined with meticulous repair of the LCLC, prevents posterolateral rotatory instability. Our results support the findings of Hotchkiss [1] and Regan and Morrey [2], who stressed the critical role of these structures in elbow stability.
Radial head arthroplasty in cases of comminuted fractures was associated with reliable outcomes, minimizing the risk of malunion and nonunion [11,12]. Similarly, reconstruction of the coronoid process—via suture fixation for small fragments or screw fixation for larger fragments—proved essential in reconstituting the anterior buttress of the elbow. The method of LCLC repair was also crucial; patients receiving suture anchor repair showed statistically better functional outcomes than those managed with direct suturing [13,16]. Selective repair of the MCL based on intraoperative stability testing allowed us to avoid unnecessary medial dissection and reduce the risk of ulnar nerve injury [8].
Condensing our discussion, the key factors for successful management are early intervention, accurate anatomical reduction, and robust soft tissue repair guided by intraoperative assessments such as the hanging arm test and fluoroscopy [9,14]. Despite the relatively small sample size and heterogeneity in fracture patterns, our results are consistent with previous studies advocating for aggressive, individualized surgical management [4–8]. Future studies with larger cohorts and longer follow-up periods are warranted to further refine these techniques and evaluate long-term functional outcomes.
Conclusion
The management of terrible triad injuries of the elbow requires a comprehensive strategy that addresses both the osseous and ligamentous components of the injury. Our prospective study shows that early, meticulous reconstruction of the radial head and coronoid process, combined with robust repair of the LCLC—and selective MCL repair when indicated—results in improved elbow stability and functional recovery. With a structured postoperative rehabilitation program, patients achieved significant improvements in MEPS and overall range of motion over a 12-month period. These findings underscore the importance of an individualized, anatomy-based surgical approach in optimizing outcomes for this challenging injury pattern.
References
1. Hotchkiss RS. The terrible triad of the elbow. Clin Orthop Relat Res. 1996;(332):78–83.
2. Regan EG, Morrey BF. Coronoid process fractures of the ulna. J Bone Joint Surg Am. 1989;71(9):1338–44.
3. Mason ML. Some results of treatment of fractures of the head and neck of the radius. J Bone Joint Surg Am. 1954;36-A:885–8.
4. Rietbergen H, Morrey BF. Fractures of the radial head: current concepts. J Bone Joint Surg Am. 2008;90(1):172–82.
5. Pugh DM, Wild LM, et al. Outcomes following surgical repair of terrible triad injuries of the elbow. J Orthop Trauma. 2002;16(7):437–44.
6. Ring D, Jupiter JB, Simpson NS. Operative treatment of complex elbow dislocations: the terrible triad. J Bone Joint Surg Am. 2002;84(9):1627–38.
7. Ashwood N, et al. Titanium radial head prosthesis in Mason type III fractures. J Trauma. 2004;56(5):1123–8.
8. Doornberg JN, Ring D, et al. Fracture morphology in terrible triad injuries. Clin Orthop Relat Res. 2006;447:123–30.
9. Forthman C, et al. Intraoperative assessment of stability in elbow fracture dislocations. J Shoulder Elbow Surg. 2007;16(4):435–40.
10. Ring D, et al. The role of radial head reconstruction in elbow stability. J Bone Joint Surg Am. 2008;90(3):450–7.
11. Clarke SE, et al. Surgical management of complex elbow fractures. Injury. 2008;39(3):270–5.
12. Lindenhovius AL, et al. Fixation techniques for coronoid fractures: a biomechanical study. J Shoulder Elbow Surg. 2008;17(2):227–33.
13. Rodriguez-Martin J, et al. Current strategies in the treatment of the terrible triad of the elbow. Injury. 2011;42(1):10–6.
14. Toros T, et al. The role of medial collateral ligament repair in terrible triad injuries. J Orthop Trauma. 2012;26(5):293–8.
15. Hastings H, Graham TJ. Heterotopic ossification in elbow trauma. J Bone Joint Surg Am. 2002;84-A(1):123–30.
16. Saxena S, et al. Principles of surgical management in terrible triad injuries. J Trauma Acute Care Surg. 2015;78(3):539–45.
17. Chen HW, et al. Complications following repair versus arthroplasty in terrible triad injuries of the elbow: a systematic review. J Orthop Surg. 2019;27(1):112–8.
18. Bohn K, et al. Demographic analysis of traumatic elbow injuries in young adults. Clin Orthop Relat Res. 2015;473(5):1576–82.
19. Fitzpatrick M, et al. Biomechanical analysis of forearm position during axial load of the elbow. J Biomech. 2012;45(6):1093–8.
20. Reichel LM. Cadaveric analysis of coronoid process morphology in elbow injuries. J Shoulder Elbow Surg. 2012;21(8):1025–30.
| How to Cite this Article: Ansari H, Pradhan C, Patil A, Puram C, Sonawane D, Shyam A, Sancheti P| Optimizing Surgical Management for Terrible Triad Injuries of the Elbow: A Prospective Outcome-Based Study | Journal of Medical Thesis | 2021 July- December; 7(2): 13-16. |
Institute Where Research was Conducted: Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
University Affiliation: Maharashtra University of Health Sciences (MUHS), Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2020
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