C. D. Cristofaro, T. H. Carter, N. R. Wickramasinghe, M. M. McQueen, T. O. White, A. D. Duckworth, Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, UK.
Clin Orthop Relat Res. 2019 Nov;477(11):2531-2540. doi: 10.1097/CORR.0000000000000876.
The evidence for treating acute, unreconstructable radial head fractures in unstable elbows with radial head replacement predominantly consists of short- to mid-term follow-up studies with a heterogenous mix of implants and operative techniques. Data on longer-term patient-reported outcomes after radial head replacement is lacking.
QUESTIONS/PURPOSES: (1) What proportion of patients undergo revision or implant removal after radial head replacement? (2) At a minimum of 8 years follow-up, what are the patient-reported outcomes (QuickDASH, Oxford Elbow Score, and EuroQol-5D)? (3) What factors are associated with a superior long-term patient-reported outcome, according to the QuickDASH?
Between September 1994 and September 2010, we surgically treated 157 patients for acute radial head fractures. We excluded patients where the radial head was excised (n = 21), internally fixed (n = 15), or replaced as a secondary procedure after failed internal fixation (n = 2). A total of 119 patients who underwent radial head replacement surgery for an acute unreconstructable fracture were included, with a mean age of 50 years (range 15 to 93 ± 19 years), and 53% of patients (63) were women. All but two implants were uncemented, loose-fitting, monopolar prostheses, of which 86% (102) were metallic and 14% (17) were silastic. Implants were only cemented if they appeared unstable within the proximal radius. Silastic implants were used in the earlier series and replaced by metallic implants starting in 2000. We reviewed electronic records to document postoperative complications and prosthesis revision and removal. A member of the local research team (THC, CDC) who was not previously involved in patient care contacted patients to confirm complications, reoperations and to obtain long-term patient-reported outcomes scores. Nineteen patients had died at the point of outcome score collection. Of the remaining 100 patients, 80 were contacted (67% of total cohort), at a median of 11 years (range 8 to 24 years) after injury. The primary outcome measure was the QuickDASH score.
Of 119 patients, 25% (30) underwent reoperation, with three patients undergoing revision and 27 patients undergoing prosthesis removal at a median of 7 months (range 0 to 125 months). Twenty-one of 30 procedures (70%) occurred within 1 year after implantation. Kaplan-Meier survivorship analysis demonstrated a cumulative implant survival rate of 71%. In the 80 patients contacted, the mean QuickDASH score was 13 ± 14, the mean Oxford Elbow Score was 43 ± 6, and the median EuroQol-5D score was 0.8 (-0.3 to 1.0). After controlling for covariates, we found that prothesis revision or removal (p = 0.466) and prosthesis type (p = 0.553) were not associated with patient-reported outcome, according to the QuickDASH.
The management of acute unreconstructable fractures of the radial head in unstable elbow injuries with radial head replacement has a high risk of reoperation. Patients must be counselled regarding this risk of secondary intervention, of which the peak risk appears to be within 1 year after implantation. Despite this, patients report low disability according to the QuickDASH at a minimum follow-up of 8 years.
Level IV, therapeutic study.
治疗不稳定肘关节中急性、不可重建的桡骨小头骨折的证据主要来自短期至中期随访研究，其中包含了各种不同的植入物和手术技术。缺乏桡骨小头置换后长期患者报告结果的数据。
问题/目的：（1）桡骨小头置换后有多少患者需要进行翻修或取出植入物？（2）至少 8 年随访时，患者报告的结果（QuickDASH、牛津肘部评分和 EuroQol-5D）如何？（3）根据 QuickDASH，哪些因素与长期患者报告结果的优越性相关？
1994 年 9 月至 2010 年 9 月，我们对 157 例急性桡骨小头骨折患者进行了手术治疗。我们排除了桡骨小头切除（n = 21）、内固定（n = 15）或内固定失败后作为二级手术置换的患者（n = 2）。共纳入 119 例接受桡骨小头置换术治疗急性不可重建骨折的患者，平均年龄为 50 岁（范围 15 至 93 ± 19 岁），53%的患者（63 例）为女性。除了两个植入物，所有的植入物都是非骨水泥、松动、单极假体，其中 86%（102 例）为金属假体，14%（17 例）为硅橡胶假体。只有在桡骨近端看起来不稳定的情况下，才会对硅橡胶植入物进行骨水泥固定。在早期系列中使用硅橡胶植入物，从 2000 年开始更换为金属植入物。我们查阅电子病历记录术后并发症和假体翻修及取出情况。当地研究团队的一名成员（THC、CDC）联系患者，确认并发症、再次手术和获取长期患者报告结果评分，该成员之前未参与患者治疗。有 19 名患者在结果评分收集时已经死亡。在剩余的 100 名患者中，有 80 名患者（总队列的 67%）接受了联系，在受伤后中位数 11 年（范围 8 至 24 年）。主要的观察指标是 QuickDASH 评分。
119 例患者中，25%（30 例）进行了再次手术，其中 3 例进行了翻修，27 例进行了假体取出，中位数时间为 7 个月（范围 0 至 125 个月）。21 例（70%）手术发生在植入后 1 年内。Kaplan-Meier 生存分析显示，累积植入物生存率为 71%。在联系的 80 例患者中，QuickDASH 评分平均为 13 ± 14，牛津肘部评分平均为 43 ± 6，EuroQol-5D 评分中位数为 0.8（-0.3 至 1.0）。在控制了协变量后，我们发现假体翻修或取出（p = 0.466）和假体类型（p = 0.553）与 QuickDASH 评分的患者报告结果无关。
不稳定肘关节中急性不可重建的桡骨小头骨折的桡骨小头置换治疗具有较高的再次手术风险。必须向患者说明这种二次干预的风险，其高峰风险似乎出现在植入后 1 年内。尽管如此，在至少 8 年的随访中，患者根据 QuickDASH 报告的残疾程度较低。
IV 级，治疗性研究。
