Capitellar Erosion Caused by a Metal Radial Head Prosthesis: A Case Report

Van Riet, Roger P. MD; Van Glabbeek, Francis MD; Verborgt, Olivier MD, PhD; Gielen, Jan MD, PhD

Journal of Bone & Joint Surgery - American Volume: May 2004 - Volume 86 - Issue 5 - p 1061–1064
Case Reports

1 Departments of Orthopaedics and Traumatology (R.P.v.R., F.V.G., and O.V.), and Radiology (J.G.), University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium. E-mail address for R.P. van Riet: roger.van.riet@uza.be

Article Outline

The long-term results of resection of the radial head for the treatment of a simple radial head fracture have been generally satisfactory1-5. However, some late complications, such as proximal migration of the radius, can disable the patient and are difficult to treat. Proximal migration of the radius is usually asymptomatic3-5, although wrist pain develops in a minority of patients3-8. The options for treatment are limited, and clinical studies have shown poor and unreliable results9,10. Sowa et al. described a case in which a silicone radial head prosthesis was implanted for the treatment of wrist symptoms10. Proximal migration of the radius progressed, and it was concluded that a more rigid implant would be necessary. Sellman et al. reached a similar conclusion after performing a biomechanical study of this problem11.

We report the case of a patient who had early progressive erosion of the capitellum after the insertion of a metal radial head prosthesis for the treatment of wrist pain following radial head resection after trauma. This complication has not been reported previously, to our knowledge. Our patient was informed that data concerning the case would be submitted for publication.

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Case Report

An eighteen-year-old woman underwent resection of the radial head after sustaining an irreparable fracture of the right radial head. Progressive wrist pain developed six months after the resection. Ulnar variance was +3 mm at that time. In July 1998, forty-four months after the resection, a floating radial head prosthesis (Tornier SA, Saint-Ismier, France) was implanted.

Preoperative radiographs showed mild degenerative changes of the elbow and some valgus positioning of the ulnohumeral joint and mild osteopenia of the capitellum (Figs. 1-A and 1-B). Surgery was performed through a lateral approach. At that time, the articular cartilage of the capitellum appeared normal on gross inspection. After resection of the radial neck at the required level, a trial prosthesis was inserted. A small prosthesis size was chosen, and the stem was cemented into the medullary canal. There was some difficulty in reducing the assembled radial head prosthesis into the radiohumeral joint. Postoperatively, the patient reported that the wrist pain was greatly reduced. Immediate postoperative radiographs (Fig. 2-A) showed no substantial change in the appearance of the capitellum in comparison with that on the preoperative radiographs.

Radiographs made at sixteen months (Fig. 2-B) and fifty-seven months (Fig. 2-C) showed that the subchondral cortical end plate of the capitellum had undergone progressive depression and sclerosis whereas the ulnar border of the capitellum had maintained its normal height. At sixteen months, radiographs showed an unchanged ulnar variance of +3 mm for the right wrist and 0 mm for the left. At fifty-seven months, the ulnar variance remained essentially unchanged. Clinically, the patient had no wrist pain, despite the lack of improvement in terms of ulnar variance. However, moderate pain and decreased mobility of the elbow were noted. According to the Mayo Elbow Performance Index12, the function of the right elbow was fair (70 of a possible 100 points) as a result of moderate pain.

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Discussion

Capitellar osteopenia is rarely encountered after resection of the radial head3,5, although the condition may be underreported because of the limited clinical implications associated with this finding. In the study by Moro et al.13, no clinical effects were associated with osteopenic changes to the capitellum after the acute placement of a metal radial head. Judet et al. specifically reported that neither capitellar osteoporosis nor cartilaginous erosion was found in three elbows in which the floating radial head prosthesis had been implanted in a delayed fashion at seven, ten, and twelve months after resection of the radial head14.

We believe that the complication in our patient was multifactorial and was principally caused by the axial forces acting on the metal prosthesis as it articulated with osteopenic bone. The metal prosthesis was probably one of the factors that caused early erosion of the capitellum in this patient. Because the stiffness of metal is greater than that of bone, the radiocapitellar contact area of the metal prosthesis is decreased in comparison with that of the native radial head15. Overstuffing of the radiohumeral joint is another factor that could have caused the erosion. Recent biomechanical studies have shown that lengthening of the radial neck results in an increased transmission of force through the radiocapitellar joint16,17. The radial head prosthesis in our patient was placed forty-four months after the initial resection of the radial head. Leaving a joint unloaded for that length of time has been shown to lead to disuse osteoporosis of the underlying subchondral bone18,19. Postoperatively, we noted progressive erosion of the capitellum. To our knowledge, this complication has not been reported previously.

The case of this patient demonstrates that, despite previous recommendations10,11,14,20, the radiographic appearance of the subchondral bone of the capitellum should be considered when a delayed implantation of a radial head prosthesis is planned.

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Department of Orthopaedics and Traumatology and the Department of Radiology, University Hospital Antwerp, Edegem, Belgium

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