synonyms: radial head arthroplasty, radial head replacement
Radial Head Replacement CPT
Radial Head Replacement Indications
Radial Head Replacement Contraindications
- Open fracture with high risk of sepsis
- Type I or II radial head fracture
- Capitellar arthritis / AVN
- Metal allergy
- Active infection
- Open epiphyses
- Elderly, low demand patient
Radial Head Replacement Alternatives
- Radial Head Fracture ORIF
- Radial head excision: may cause decreased grip strength, wrist pain, and progressive valgus instability
Radial Head Replacement Pre-op Planning / Special Considerations
- Pre-operatively template component size based on xrays of the normal side.
- Ensure manufacture implants and instruments are available.
- Always err on side of placing a smaller implant; avoid overstuffing the joint with an implant that is to long or to large.
- Biomet ExpoR Radial Head replacement.
Radial Head Replacement Technique
- Pre-operative antibiotic
- Supine position (with arm table, or arm can be brought across chest)
- Exam under anesthesia. Normal elbow ROM: Flexion/extension=0-135, Suppination=90, Pronation=90. Varus / Valgus stability. Evaluate wrist stability.
- Tourniquet placed high on arm
- Prep and drape in standard sterile fashion
- Kocher lateral incision centered over radial head. Consider posterior incision if there is a potential need for medial reconstruction. Exposure is performed with the forearm pronated to decrease risk of PIN injury. Dissection distal to the radial neck is avoided.
- Interval between the anconeus and extensor carpi ulnaris opened.
- ECU elevated exposing the capsule and lateral collateral ligament.
- Incise capsule anterior to the LCL complex.
- Exposure is extended as needed. If release of the LCL / extensor origin is needed it should be taken off the lateral epicondyle.
- Radial head fragments are removed and reconstructed on the back table to ensure all bone is removed from the joint.
- See manufactures technique for specific proximal radius preparation and radial head prosthesis implantation technique.
- Evenly resect the radial neck perpendicular to its axis 14mm from the capitellum. Size of resection is depended on implant used and fracture configuration. The radial osteotomy is the key to the procedure. A malaligned radial osteotomy will cause abnormal tracking during ROM, pain, capitellar DJD etc.
- Rasp radial canal until cortical resistance is felt. The rasp should be pointed toward the capitellum during rasping for proper alignment.
- Trial components are placed and the elbow is placed through a full ROM including suppination / pronation ensuring proper size, alignment and varus-valgus stability.
- Final components are press fit or cemented using standard technique. If cementing the final implant size should be 2mm smaller than the final broach size to ensure a proper cement mantle.
- Close in layers. Ensure LCL is restored during closure.
Radial Head Replacement Complications
- Heterotopic ossification
- Capitellar arthritis / erosion (van Riet RP, JBJS 2004;86A:1061)
- Ulnar neuropathy
- PIN palsy
- Decreased grip, pronation and supination strength (Moro JK, JBJS 2001;83-A:1201).
- Risks of anesthesia including heart attack, stroke and death
Radial Head Replacement Follow-up care
- Post-op: Splint with forearm in supination or neutral. Start early active range of motion as soon as possible. Indomethacin 75mg QD/NSAIDs for HOreduction.
- 7-10 Days: Evaluate incision, remove stitches, Begin early active range of motion as soon as possible. Consider hinged elbow brace for high energy injuries/instability. Start physical therapy. Avoid flexion in pronation. Patients with Essex-Loprestic injuries are held in full supination for 3-4 weeks.
- 6 Weeks: Consider static progressive nightime extension splinting if a flexion contracture is present 6 weeks after injury. 10° to 15° flexion contractures are not uncommon. If DRUJ treated by pinning remove pins at 6wks.
- 3 Months: Progress with ROM. May take 6-12 months to regain ROM. Begin sport specific therapy.
- 6 Months: May return to full activities provided patient is asymptomatic. Athletic activity that loads the radiocapitellar joint is not recommended after radial head replacement due to concerns for loosening and long-term increase in arthritic symptoms.
- 1Yr: Assess outcomes, repeat xrays.
- Radial Head Fracture Rehab Protocol
- See also Elbow Outcome Measures.
Radial Head Replacement Outcomes
- 68% good or excellent, 20% fair, 12% poor. Subjective patient satisfaction = 9.2/10. Flexion =140° ± 9°; extension, -8° ± 7°; pronation, 78° ± 9°; supination, 68° ± 10° with mild decreases in isometric forearm pronation (17%) supination (18%) and grip strength (Moro JK, JBJS 2001;83A;1201).
- 19% mild osteoarthritis for modular radial head replacement (Grewal R, JBJS 2006;88:2192).
- See also Elbow Outcome Measures.
Radial Head Replacement Review References