Streck M, Vlček M, Veigl D, Pech J, Landor I
I. chirurgická klinika hrudní, břišní a úrazové chirurgie Všeobecné fakultní nemocnice a 1. lékařské fakulty Univerzity Karlovy, Praha.
I. ortopedická klinika 1. lékařské fakulty Univerzity Karlovy a Fakultní nemocnice v Motole, Praha.
Acta Chir Orthop Traumatol Cech. 2024;91(2):96-102. doi: 10.55095/ACHOT2024/012.
This manuscript aims to identify an indication algorithm for the surgical treatment of radial head fractures associated with elbow dislocation. The study compares the mid-term functional outcomes of patients with multifragment radial head fracture treated by resection with the outcomes of patients treated with radial head replacement.
The cohort of 34 patients who sustained a radial head fracture at the mean age of 42.5 years (age range 20-81 years) was broken down into two groups by type of surgery. The EXT group consists of 20 patients with the radial head fracture treated by radial head resection. The END group includes 14 patients treated with the radial head replacement. In all patients, the radial head fracture was associated with elbow dislocation (type IV fracture according to the Mason-Johnston classification). The modified Kocher's surgical approach was used in all patients of both the groups. In the EXT group, resection of the fragmented radial head was performed. In the END group, the ExploR® Modular Radial Head System (Zimmer, Biomet, USA) was used, consisting of a CoCr (cobalt chromium) alloy head and a titanium stem. The pain and the range of motion of the elbow and forearm were evaluated after the completion of the outpatient rehabilitation (the mean follow-up period was 2.4 years). Simultaneously, the elbow joint stability was assessed. Radiographs were taken to detect heterotopic ossifications, proximalization of the radius, and any signs of prosthesis loosening. The frequency of reoperations was followed-up. The MEPS (Mayo Elbow Performance Score) was calculated.
In the EXT group, the mean elbow flexion was 117.5° and the mean pronation/supination was 166.9°. In 50% of patients, the MEPS obtained was greater than 90 points, which means an excellent functional outcome. In 1 patient (5%), recurrent elbow dislocation occurred which was the reason for revision surgery (elbow transfixation with the Kirschner wires and medial collateral ligament suture). Revision surgery was also performed in 2 patients (10%) in whom not all the radial head fragments were removed. Moreover, also observed was elbow joint instability (2 patients) and temporary radial nerve paralysis (1 patient). In 1 case discrete proximalization of the radius developed. The patients in the END group showed the mean elbow flexion of 112° and the mean pronation/supination of 135°. The MEPS obtained from 69% of patients was greater than 90 points, which means an excellent outcome. The pain under load was reported by 3 patients (21%). In 5 patients (35%), the X-rays showed radiolucent zone around the stem of the prosthesis. Neither revision surgery, nor prosthesis removal has been performed yet in any patient. No instability, neurological complications or infections have been reported. In both EXT and END group heterotopic ossifications have developed in 4 patients.
Radial head replacement compared to the radial head resection in the management of multifragment fractures associated with elbow dislocations increase the elbow and forearm stability. The group of patients with an implanted radial head prosthesis shows a higher percentage of patients achieving excellent functional outcome than the group of patients with radial head resection.
radial head, elbow, fracture, dislocation, resection, prosthesis.
本手稿旨在确定一种针对与肘关节脱位相关的桡骨头骨折的手术治疗指征算法。该研究比较了采用切除术治疗的多片段桡骨头骨折患者与采用桡骨头置换术治疗的患者的中期功能结局。
34例平均年龄42.5岁（年龄范围20 - 81岁）发生桡骨头骨折的患者队列，根据手术类型分为两组。EXT组由20例接受桡骨头切除术治疗桡骨头骨折的患者组成。END组包括14例接受桡骨头置换术治疗的患者。所有患者的桡骨头骨折均与肘关节脱位相关（根据梅森 - 约翰斯顿分类为IV型骨折）。两组所有患者均采用改良的科赫手术入路。在EXT组，对碎裂的桡骨头进行切除。在END组，使用ExploR®模块化桡骨头系统（美国齐默生物公司），该系统由钴铬合金头和钛柄组成。在门诊康复完成后（平均随访期为2.4年）评估肘部和前臂的疼痛及活动范围。同时，评估肘关节稳定性。拍摄X线片以检测异位骨化、桡骨近端移位以及假体松动的任何迹象。对再次手术的频率进行随访。计算梅奥肘关节功能评分（MEPS）。
在EXT组，平均肘关节屈曲角度为117.5°，平均旋前/旋后角度为166.9°。50%的患者获得的MEPS大于90分，这意味着功能结局极佳。1例患者（5%）发生复发性肘关节脱位，这是翻修手术的原因（用克氏针固定肘关节和缝合内侧副韧带）。另外2例患者（10%）因未完全切除所有桡骨头碎片也进行了翻修手术。此外，还观察到肘关节不稳定（2例患者）和暂时性桡神经麻痹（1例患者）。1例出现桡骨离散性近端移位。END组患者的平均肘关节屈曲角度为112°，平均旋前/旋后角度为135°。69%的患者获得的MEPS大于90分，这意味着结局极佳。3例患者（21%）报告有负重时疼痛。5例患者（35%）的X线片显示假体柄周围有透亮区。尚无患者进行翻修手术或取出假体。未报告有不稳定、神经并发症或感染情况。EXT组和END组均有4例患者发生异位骨化。
在处理与肘关节脱位相关的多片段骨折时，与桡骨头切除术相比，桡骨头置换术可增加肘关节和前臂的稳定性。植入桡骨头假体的患者组比接受桡骨头切除术的患者组中获得极佳功能结局的患者百分比更高。
桡骨头；肘关节；骨折；脱位；切除术；假体
