Mr Sherif Isaac FRCS 1; Mr James Pegrum MRCS (Eng)2 Open reduction and internal fixation versus radial head arthroplasty for Mason III radial head fractures: Appraising the current literature evidence Mr Sherif Isaac FRCS 1; Mr James Pegrum MRCS (Eng)2 1 Consultant orthopaedic surgeon at Heatherwood and Wexham Park Hospital, Slough 2 Specialist Registrar Oxford rotation and honorary research associate Queen Mary University of London Introduction: Fractures of the radial head are common and account for one-third of elbow fractures. The management has evolved over the past few decades as have the techniques and implants used to treat them. The biomechanics of the elbow and latest evidence no longer favour excision arthroplasty. 1-3 This review discusses the debatable aspects of management between open reduction and internal fixation (ORIF) and arthroplasty, in light of the current best evidence. Aims & Objectives: The purpose of this study was to systematically review the current literature that assessed open reduction and internal fixation compare to radial head replacement to identify the best surgical treatment protocol for the management of Mason type III radial head fracture. Mason Classification:4 Methods: All published clinical trials claiming to evaluate or cited elsewhere as being authoritative regarding the surgical treatment of radial head fractures were identified and evaluated. Studies in foreign languages (not in English) were excluded. Summary of Key Papers Statistical Analysis Conclusion: Satisfactory treatment of Mason type III fractures can be achieved with radial head arthroplasty. Unstable elbows, fixation of multi-fragmented fractures and younger age fair worse. The use of Silastic implants are to be avoided. Replacement may be a better option to choose when treating these complex fractures but the current evidence is week based on this review. Therefore, this review should stimulate researchers to set up a multicentre prospective randomised trial with appropriate sample size to compare ORIF with arthroplasty treatment options. Psychological and sociological factors must also be taken into account as these are important determinants of symptoms and disability. Practical Implications: References: Author Study Type Number of subjects Main conclusions Ruan5 RCT 22 Favored replacement Chen6 45 Reduced complications and improved outcomes with replacement Rin7 Prospective 26 >3 fragments worse outcome after ORIF, 10/26 required 2nd operation Helling8 165 Reduced complications with bioabsorbable ORIF vs metallic ORIF Yoon9 Retrospective 60 No benefit for ORIF vs non surgical management of displaced radial head fractures between 2-5mm Pelto10 19 1/19 patients underwent further surgery with bioabsorbable fixation screws Watters11 39 Improved outcomes in replacement vs ORIF Dislocated elbows worse outcome Flinkkila12 37 12 radial head replacement loose at 50 months Duckworth13 105 Radial head revision rate increased in silastic implants and age <50 Unstable elbows and the younger age group fair worse despite any treatment option used Metallic over silastic implants should be used Radial head excision should be avoided except in low functional individuals Grade Description I Non displaced II Partial fractures with >2mm displacement III Comminuted fractures Ikeda, M., et al., Comminuted fractures of the radial head: comparison of resection and internal fixation. Surgical technique. J Bone Joint Surg Am, 2006. 88 Suppl 1 Pt 1: p. 11-23.. Morrey, B.F., K.N. An, and T.J. Stormont, Force transmission through the radial head. J Bone Joint Surg Am, 1988. 70(2): p. 250-6. Hall, J.A. and M.D. McKee, Posterolateral rotatory instability of the elbow following radial head resection. J Bone Joint Surg Am, 2005. 87(7): p. 1571-9. Mason, M.L., Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg, 1954. 42(172): p. 123-32. Ruan, H.J., et al., A comparative study of internal fixation and prosthesis replacement for radial head fractures of Mason type III. Int Orthop, 2009. 33(1): p. 249-53. Chen, X., et al., Comparison between radial head replacement and open reduction and internal fixation in clinical treatment of unstable, multi-fragmented radial head fractures. Int Orthop, 2011. 35(7): p. 1071-6. Ring, D., J. Quintero, and J.B. Jupiter, Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am, 2002. 84-A(10): p. 1811-5. Helling, H.J., et al., Biodegradable implants versus standard metal fixation for displaced radial head fractures. A prospective, randomized, multicenter study. J Shoulder Elbow Surg, 2006. 15(4): p. 479-85. Yoon A., et al., Is ORIF Superior to Nonoperative Treatment in Isolated Displaced Partial Articular Fractures of the Radial Head? Clin Orthop Relat Res. 2014 Feb 28 Pelto, K., et al., Treatment of radial head fractures with absorbable polyglycolide pins: a study on the security of the fixation in 38 cases. J Orthop Trauma, 1994. 8(2): p. 94-8. Watters, T.S., et al., Fixation Versus Replacement of Radial Head in Terrible Triad: Is There a Difference in Elbow Stability and Prognosis? Clin Orthop Relat Res, 2013. Flinkkila, T., et al., Short- to mid-term results of metallic press-fit radial head arthroplasty in unstable injuries of the elbow. J Bone Joint Surg Br, 2012. 94(6): p. 805-10. Duckworth, A.D., et al., Radial Head Replacement for Acute Complex Fractures: What Are the Rate and Risks Factors for Revision or Removal? Clin Orthop Relat Res, 2014.