Diez Sánchez Blanca, Barco Raúl, Antuña Samuel A
Upper Limb Unit, Hospital Universitario La Paz, Madrid, Spain.
Upper Limb Unit, Hospital Universitario La Paz, Madrid, Spain.
J Shoulder Elbow Surg. 2023 Dec;32(12):2581-2589. doi: 10.1016/j.jse.2023.07.023. Epub 2023 Aug 22.
Radial head fractures not amenable to reconstruction should be treated by radial head replacement (RHR) when there is associated elbow or forearm instability. There are multiple RHR designs with different philosophies, but 2 of the most commonly used implants include the anatomic press-fit radial head system and the loose-fit metallic spacer. There is little information available specifically comparing the long-term clinical and radiographic outcomes of these 2 systems. The objective of this study was to compare the long-term clinical and radiologic outcomes of 2 RHR designs in the context of complex acute elbow instability.
Ninety-five patients with an average age of 54 years (range, 21-87 years) underwent an acute RHR (46 press-fit Acumed anatomic and 49 loose-fit Evolve metallic spacer) and were prospectively followed for an average of 61 months (range, 24-157 months). There were 34 terrible triads; 36 isolated RH fractures with medial, lateral, or longitudinal instability; and 25 RH fractures associated with a proximal ulnar fracture. Clinical outcome and disability were evaluated with the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score, and the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Pain and satisfaction were assessed using a visual analog scale. Radiographic analysis included presence of loosening, bone loss, and overstuffing related to the RHR.
Eight patients with an anatomic RHR (2 with overstuffing, 3 for stiffness, and 3 with loose implants) and 1 patient with a spacer (with stiffness) required implant removal. There were no significant differences between spacer RHR and anatomic RHR in arc of motion (120° vs. 113°, P = .14), pain relief (1 vs. 1.7, P = .135), MEPS (94 vs. 88; P = .07), Oxford Elbow Score (42.3 vs. 42.2, P = .4), or DASH score (12.2 vs. 14.4, P = .5). However, patients with a spacer RHR were significantly more satisfied (9 vs. 7.7; P = .004) than those with an anatomic implant. Radiographically, 19 anatomic implants had significant proximal bone loss and 10 showed complete lucent lines around the stem. Lucent lines were common around the spacer RHR. These radiographic changes were not always related to worse clinical outcomes.
Both the anatomic and spacer RHR designs can provide good clinical long-term outcomes. However, patients with a spacer showed a higher degree of satisfaction and those with an anatomic press-fit RHR had a higher revision rate, with radiographic changes that warrant continued follow-up.
当合并肘部或前臂不稳时，无法进行重建的桡骨头骨折应采用桡骨头置换术（RHR）治疗。有多种RHR设计理念不同，但最常用的两种植入物包括解剖型压配式桡骨头系统和松配式金属间隔物。关于这两种系统长期临床和影像学结果的具体比较信息很少。本研究的目的是在复杂急性肘部不稳的情况下比较两种RHR设计的长期临床和放射学结果。
95例平均年龄54岁（范围21 - 87岁）的患者接受了急性RHR（46例解剖型压配式Acumed，49例松配式Evolve金属间隔物），并进行前瞻性随访，平均随访61个月（范围24 - 157个月）。其中有34例可怕三联征；36例孤立性桡骨头骨折伴内侧、外侧或纵向不稳；25例桡骨头骨折合并尺骨近端骨折。采用梅奥肘关节功能评分（MEPS）、牛津肘关节评分和上肢、肩部和手部功能障碍（DASH）评分评估临床结果和残疾情况。使用视觉模拟量表评估疼痛和满意度。影像学分析包括与RHR相关的松动、骨丢失和填充过度情况。
8例解剖型RHR患者（2例填充过度，3例僵硬，3例植入物松动）和1例间隔物患者（僵硬）需要取出植入物。间隔物RHR和解剖型RHR在活动弧（120°对113°，P = 0.14）、疼痛缓解（1对1.7，P = 0.135）、MEPS（94对88；P = 0.07）、牛津肘关节评分（42.3对42.2，P = 0.4）或DASH评分（12.2对14.4，P = 0.5）方面无显著差异。然而，间隔物RHR患者比解剖型植入物患者满意度显著更高（9对7.7；P = 0.004）。影像学上，19例解剖型植入物有明显的近端骨丢失，10例在柄周围显示完整的透亮线。间隔物RHR周围透亮线很常见。这些影像学改变并不总是与更差的临床结果相关。
解剖型和间隔物RHR设计均可提供良好的长期临床结果。然而，间隔物患者满意度更高，解剖型压配式RHR患者翻修率更高，影像学改变值得继续随访。
