J Shoulder Elbow Surg (2015) 24, e27-e29
www.elsevier.com/locate/ymse
CASE REPORT
Sixty-nine-year follow-up of a McKee radial head arthroplasty Paul M. Robinson, FRCS (Tr&Orth)*, Peter Chapman, FRCS (Orth) Department of Trauma and Orthopaedics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK Radial head arthroplasty has developed into a reliable treatment of degenerative joint disease, comminuted radial head fractures, and complex elbow and forearm injuries. We report a previously unknown radial head implant, designed and implanted by Kenneth McKee in 1944, in what we believe to be the longest follow-up report of any radial head prosthesis.
Case An 89-year-old woman presented to the emergency department in April 2013 after falling and sustaining injuries to her left shoulder and elbow. On examination, the elbow was bruised and painful, with minor soft tissue swelling. There was a well-healed surgical scar on the lateral aspect of the elbow. Radiographs revealed a fracture of the left proximal humerus and degenerative changes in the left elbow with a radial head prosthesis in situ (Fig. 1). The prosthesis appeared loose with some fragmentation. The patient was managed conservatively with a broad-arm sling and advice to mobilize the elbow as her pain allowed. The elbow pain subsequently settled. On further questioning in the fracture clinic, it transpired that at the age of 20 years, the patient had fallen from a bicycle during the Second World War, in 1944, suffering a closed fracture of the left radial head. The elbow was not dislocated. She was seen at the Norfolk and Norwich Hospital on the following day, where the diagnosis was IRB/Ethical Committee approval: None was required for a case report. *Reprint requests: Paul M. Robinson, FRCS (Tr&Orth), Department of Orthopaedics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY. E-mail address: [email protected] (P.M. Robinson).
confirmed with radiographs. The patient was operated on 1 day later by the orthopedic surgeon Mr. Kenneth McKee, who implanted an ‘‘experimental’’ radial head prosthesis that he himself had designed. The patient made an uneventful recovery and states that she had no further problems with the elbow. The patient recalled experiencing a brief episode of pain in the elbow in 1973, and a radiograph of the elbow was performed in July of the same year (Fig. 2). She saw Mr. McKee at the time and on his advice went on holiday as planned and ‘‘swam every day in the sea.’’ Each day, her elbow symptoms improved, and by the end of the holiday, the pain had resolved completely. She had no further discomfort from the elbow until her fall almost 40 years later. The patient was reviewed in our clinic in September 2013, at which time the elbow was asymptomatic and her discomfort had resolved. On examination of the elbow, there was 30 of fixed flexion, and she could flex the elbow up to 140 . She had full pronation, and she lacked the last 50 of supination. All of these movements were pain free. She had 150 of elevation of the ipsilateral shoulder. The patient was still living independently and mobilizing with the use of a frame. Her Disabilities of the Arm, Shoulder, and Hand (DASH) score6 was 32, and her Oxford elbow score4 was 47. She was discharged from the clinic at that time.
Discussion There are few long-term follow-up studies of radial head arthroplasty. A systematic review of the literature found 21 level IV studies, none of which performed survivorship analysis.8 One of the studies with the longest follow-up is that of Harrington et al,5 which described 20 patients who
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.09.030
e28
P.M. Robinson, P. Chapman
Figure 1
(A and B) Anteroposterior and lateral radiographs of the injured elbow taken in 2013.
Figure 2 Anteroposterior and lateral radiographs of the elbow with radial head prosthesis in situ taken in 1973.
had undergone titanium radial head arthroplasty for fractures associated with elbow instability. The mean follow-up was 12.1 years, ranging from 6 to 29 years. Historically, the indication for a radial head ‘‘cap’’ was to prevent heterotopic ossification. Speed11 published the earliest account of radial head arthroplasty in 1941. The indication gradually changed, and Carr and Howard2 were the first to discuss arthroplasty in the context of elbow stability. A variety of materials have been used with varying degrees of success.1,3,7,9,10,12 These include metals (copper, Vitallium, cobalt chromium, and titanium), acrylic resin, silicone rubber, and pyrocarbon. G. K. McKee CBE was appointed consultant orthopaedic surgeon at the Norfolk and Norwich Hospital in 1939. He worked with an engineering firm in Norwich designing implants that would later evolve into the pioneering McKee-Farrar total hip replacement. However, little is known about the other implants that he designed and used in clinical practice. He is known to have designed and
implanted prostheses for other joints, including a total elbow replacement. We were previously unaware of the existence of the radial head prosthesis described in this report, and we do not know how many were actually implanted. Unfortunately, there are no other records of the implant in existence because of its age and the loss of medical records from that era. We hypothesize that the radial head prosthesis was made from the metal alloy Vitallium, as this was the material of the McKee-Farrar total hip replacement. At the time of surgery, Mr. McKee informed the patient that this was an experimental procedure and he was unable to predict the outcome. Although the procedure was clinically successful, the radiographic appearances are those of a failing prosthesis, with loosening and migration of the implant. However, it is recognized that radiographic degenerative change is not always clinically apparent in some individuals.
Conclusion We have reported a 69-year clinical and radiologic follow-up of a previously unknown radial head prosthesis. Clinically, the implant was successful; however, it showed radiologic signs of failure.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
McKee radial head arthroplasty
e29
References 7. 1. Beredjiklian PK, Nalbantoglu U, Potter HG, Hotchkiss RN. Prosthetic radial head components and proximal radial morphology: a mismatch. J Shoulder Elbow Surg 1999;8:471-5. 2. Carr CR, Howard JW. Metallic cap replacement of radial head following fracture. West J Surg Obstet Gynecol 1951;59:539-46. 3. Cherry JC. Use of acrylic prosthesis in the treatment of fracture of the head of the radius. J Bone Joint Surg Br 1953;35:70-1. 4. Dawson J, Doll H, Boller I, Fitzpatrick R, Little C, Rees J, et al. The development and validation of a patient-reported questionnaire to assess outcomes of elbow surgery. J Bone Joint Surg Br 2008;90: 466-73. http://dx.doi.org/10.1302/0301-620X.90B4.20290 5. Harrington IJ, Sekyi-Otu A, Barrington TW, Evans DC, Tuli V. The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: a long-term review. J Trauma 2001;50: 46-52. 6. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm,
8.
9.
10.
11. 12.
shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med 1996;29:602-8. Judet T, Garreau de Loubresse C, Piriou P, Charnley G. A floating prosthesis for radial-head fractures. J Bone Joint Surg Br 1996;78:244-9. Kaur MN, MacDermid JC, Grewal RR, Stratford PW, Woodhouse LJ. Functional outcomes post-radial head arthroplasty: a systematic review of literature. Shoulder Elbow 2014;6:108-18. http://dx.doi.org/ 10.1177/1758573214524934 Knight DJ, Rymaszewski LA, Amis AA, Miller JH. Primary replacement of the fractured radial head with a metal prosthesis. J Bone Joint Surg Br 1993;75:572-6. Ricon FJ, Sanchez P, Lajara F, Galan A, Lozano JA, Guerado E. Result of a pyrocarbon prosthesis after comminuted and unreconstructable radial head fractures. J Shoulder Elbow Surg 2012;21:82-91. http://dx. doi.org/10.1016/j.jse.2011.01.032 Speed K. Ferrule caps for the head of the radius. Surg Gynecol Obstet 1941;73:845-50. Swanson AB, Jaeger SH, La Rochelle D. Comminuted fractures of the radial head. The role of silicone-implant replacement arthroplasty. J Bone Joint Surg Am 1981;63:1039-49.
www.elsevier.com/locate/ymse
CASE REPORT
Sixty-nine-year follow-up of a McKee radial head arthroplasty Paul M. Robinson, FRCS (Tr&Orth)*, Peter Chapman, FRCS (Orth) Department of Trauma and Orthopaedics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK Radial head arthroplasty has developed into a reliable treatment of degenerative joint disease, comminuted radial head fractures, and complex elbow and forearm injuries. We report a previously unknown radial head implant, designed and implanted by Kenneth McKee in 1944, in what we believe to be the longest follow-up report of any radial head prosthesis.
Case An 89-year-old woman presented to the emergency department in April 2013 after falling and sustaining injuries to her left shoulder and elbow. On examination, the elbow was bruised and painful, with minor soft tissue swelling. There was a well-healed surgical scar on the lateral aspect of the elbow. Radiographs revealed a fracture of the left proximal humerus and degenerative changes in the left elbow with a radial head prosthesis in situ (Fig. 1). The prosthesis appeared loose with some fragmentation. The patient was managed conservatively with a broad-arm sling and advice to mobilize the elbow as her pain allowed. The elbow pain subsequently settled. On further questioning in the fracture clinic, it transpired that at the age of 20 years, the patient had fallen from a bicycle during the Second World War, in 1944, suffering a closed fracture of the left radial head. The elbow was not dislocated. She was seen at the Norfolk and Norwich Hospital on the following day, where the diagnosis was IRB/Ethical Committee approval: None was required for a case report. *Reprint requests: Paul M. Robinson, FRCS (Tr&Orth), Department of Orthopaedics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY. E-mail address: [email protected] (P.M. Robinson).
confirmed with radiographs. The patient was operated on 1 day later by the orthopedic surgeon Mr. Kenneth McKee, who implanted an ‘‘experimental’’ radial head prosthesis that he himself had designed. The patient made an uneventful recovery and states that she had no further problems with the elbow. The patient recalled experiencing a brief episode of pain in the elbow in 1973, and a radiograph of the elbow was performed in July of the same year (Fig. 2). She saw Mr. McKee at the time and on his advice went on holiday as planned and ‘‘swam every day in the sea.’’ Each day, her elbow symptoms improved, and by the end of the holiday, the pain had resolved completely. She had no further discomfort from the elbow until her fall almost 40 years later. The patient was reviewed in our clinic in September 2013, at which time the elbow was asymptomatic and her discomfort had resolved. On examination of the elbow, there was 30 of fixed flexion, and she could flex the elbow up to 140 . She had full pronation, and she lacked the last 50 of supination. All of these movements were pain free. She had 150 of elevation of the ipsilateral shoulder. The patient was still living independently and mobilizing with the use of a frame. Her Disabilities of the Arm, Shoulder, and Hand (DASH) score6 was 32, and her Oxford elbow score4 was 47. She was discharged from the clinic at that time.
Discussion There are few long-term follow-up studies of radial head arthroplasty. A systematic review of the literature found 21 level IV studies, none of which performed survivorship analysis.8 One of the studies with the longest follow-up is that of Harrington et al,5 which described 20 patients who
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.09.030
e28
P.M. Robinson, P. Chapman
Figure 1
(A and B) Anteroposterior and lateral radiographs of the injured elbow taken in 2013.
Figure 2 Anteroposterior and lateral radiographs of the elbow with radial head prosthesis in situ taken in 1973.
had undergone titanium radial head arthroplasty for fractures associated with elbow instability. The mean follow-up was 12.1 years, ranging from 6 to 29 years. Historically, the indication for a radial head ‘‘cap’’ was to prevent heterotopic ossification. Speed11 published the earliest account of radial head arthroplasty in 1941. The indication gradually changed, and Carr and Howard2 were the first to discuss arthroplasty in the context of elbow stability. A variety of materials have been used with varying degrees of success.1,3,7,9,10,12 These include metals (copper, Vitallium, cobalt chromium, and titanium), acrylic resin, silicone rubber, and pyrocarbon. G. K. McKee CBE was appointed consultant orthopaedic surgeon at the Norfolk and Norwich Hospital in 1939. He worked with an engineering firm in Norwich designing implants that would later evolve into the pioneering McKee-Farrar total hip replacement. However, little is known about the other implants that he designed and used in clinical practice. He is known to have designed and
implanted prostheses for other joints, including a total elbow replacement. We were previously unaware of the existence of the radial head prosthesis described in this report, and we do not know how many were actually implanted. Unfortunately, there are no other records of the implant in existence because of its age and the loss of medical records from that era. We hypothesize that the radial head prosthesis was made from the metal alloy Vitallium, as this was the material of the McKee-Farrar total hip replacement. At the time of surgery, Mr. McKee informed the patient that this was an experimental procedure and he was unable to predict the outcome. Although the procedure was clinically successful, the radiographic appearances are those of a failing prosthesis, with loosening and migration of the implant. However, it is recognized that radiographic degenerative change is not always clinically apparent in some individuals.
Conclusion We have reported a 69-year clinical and radiologic follow-up of a previously unknown radial head prosthesis. Clinically, the implant was successful; however, it showed radiologic signs of failure.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
McKee radial head arthroplasty
e29
References 7. 1. Beredjiklian PK, Nalbantoglu U, Potter HG, Hotchkiss RN. Prosthetic radial head components and proximal radial morphology: a mismatch. J Shoulder Elbow Surg 1999;8:471-5. 2. Carr CR, Howard JW. Metallic cap replacement of radial head following fracture. West J Surg Obstet Gynecol 1951;59:539-46. 3. Cherry JC. Use of acrylic prosthesis in the treatment of fracture of the head of the radius. J Bone Joint Surg Br 1953;35:70-1. 4. Dawson J, Doll H, Boller I, Fitzpatrick R, Little C, Rees J, et al. The development and validation of a patient-reported questionnaire to assess outcomes of elbow surgery. J Bone Joint Surg Br 2008;90: 466-73. http://dx.doi.org/10.1302/0301-620X.90B4.20290 5. Harrington IJ, Sekyi-Otu A, Barrington TW, Evans DC, Tuli V. The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: a long-term review. J Trauma 2001;50: 46-52. 6. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm,
8.
9.
10.
11. 12.
shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med 1996;29:602-8. Judet T, Garreau de Loubresse C, Piriou P, Charnley G. A floating prosthesis for radial-head fractures. J Bone Joint Surg Br 1996;78:244-9. Kaur MN, MacDermid JC, Grewal RR, Stratford PW, Woodhouse LJ. Functional outcomes post-radial head arthroplasty: a systematic review of literature. Shoulder Elbow 2014;6:108-18. http://dx.doi.org/ 10.1177/1758573214524934 Knight DJ, Rymaszewski LA, Amis AA, Miller JH. Primary replacement of the fractured radial head with a metal prosthesis. J Bone Joint Surg Br 1993;75:572-6. Ricon FJ, Sanchez P, Lajara F, Galan A, Lozano JA, Guerado E. Result of a pyrocarbon prosthesis after comminuted and unreconstructable radial head fractures. J Shoulder Elbow Surg 2012;21:82-91. http://dx. doi.org/10.1016/j.jse.2011.01.032 Speed K. Ferrule caps for the head of the radius. Surg Gynecol Obstet 1941;73:845-50. Swanson AB, Jaeger SH, La Rochelle D. Comminuted fractures of the radial head. The role of silicone-implant replacement arthroplasty. J Bone Joint Surg Am 1981;63:1039-49.
