Temporary Cemented Spacer for Complex Radial Head Fractures: A Case Report

Introduction

The elbow is a complex joint comprising 3 articulations: the radiocapitellar joint, the proximal radioulnar joint, and the ulnohumeral joint. Its stability and function are maintained by a combination of static and dynamic stabilizers [1]. The radial head is elliptically shaped with a concave articular surface, and its dimensions exhibit interindividual variability. It articulates with the convex capitellum of the humerus [2].

Radial head fractures (RHFs) are the most frequent fractures of the elbow, accounting for up to one-third of all elbow fractures and approximately 4% of all fractures across the body. These injuries significantly impair upper-limb function, given the radial head’s critical role in resisting valgus stresses and contributing to posterolateral elbow stability, as demonstrated by Morrey et al [3].

RHFs typically result from falls onto an outstretched hand, wherein an axial load is transmitted through the extended and pronated forearm. The modified Mason classification remains the most widely used system for categorizing radial head fractures. Mason type I encompasses minimally displaced or nondisplaced fractures; type II includes displaced fractures involving the radial head’s marginal sector; type III refers to comminuted fractures affecting the entire radial head; and type IV describes radial head fractures associated with elbow dislocation [4].

Management strategies for RHFs vary widely and include nonoperative treatment, open reduction and internal fixation (ORIF), radial head arthroplasty (RHA), and radial head resection. Despite the array of available interventions, no definitive consensus has been reached regarding the optimal treatment approach for all fracture types. Currently, in addition to displacement greater than 2 mm and fracture comminution, other radiographic parameters have been proposed as indicators for surgical intervention [5].

The choice of treatment for Mason III–IV fractures is influenced by numerous factors, including fracture characteristics and patient-specific considerations such as age, functional demands, expectations, and the presence of a mechanical block [6]. Treatment options in these cases encompass ORIF, RHA, or early or delayed radial head resection (RHR). Historically, before the advent of low-profile fixation plates and advances in arthroplasty techniques, radial head resection was considered the treatment of choice for Mason III fractures [7].

The presence of concomitant injuries to surrounding structures – such as the collateral ligaments, joint capsule, and epicondylar muscles – is pivotal in therapeutic decision-making. Comprehensive evaluation and management of these stabilizing structures are essential to optimize outcomes and prevent residual elbow instability [8,9].

In a recent systematic review and network meta-analysis of randomized controlled trials (RCTs), Haines et al evaluated the comparative efficacy of various treatment modalities for displaced RHFs [10]. Nevertheless, despite these contributions, the current body of high-quality RCTs remains limited, underscoring the need for further rigorous investigations to establish standardized treatment guidelines for this condition.

Case Report

PREOPERATIVE ASSESSMENT:

Radiological studies (AP and lateral views of the left elbow) showed a complex, complete, multifragmented, fully articular fracture of the radial head with a 2 cm displacement of the largest fragment in the medial aspect of the elbow, with the rest showing no alterations and preserved joint congruence (Figure 1). Given the complexity of the injury, it was decided to perform a more specific study for surgical planning, a computed tomography (CT) scan, which would help better characterize the current state of the injury (Figure 2). The diagnosis was established as a left radial head fracture Mason III (AO 2R1A).

INTRAOPERATIVE DECISION-MAKING:

The patient was admitted and originally scheduled for an open reduction and external fixation with an anatomical plate; however, upon seeing that the reduction was not possible due to its complexity, we decided to perform a resection of the left radial head (Figure 3) with placement of a cemented bone spacer because a radial head prosthesis was not available.

SURGICAL TECHNIQUE:

Standard anesthesiology management was performed with the placement of regional blockade. The patient was positioned in the lateral decubitus position, and tests were conducted to assess the joint with varus-valgus stress and compression-distraction with vertical stability testing, revealing clear instability of the elbow. A lateral Kocher approach was used.

Dissection was performed by layers, identifying the fascia and the space between the anconeus muscle and the extensor carpi ulnaris muscle. The dissection proceeded, identifying the annular ligament, which was dissected, and fragments of the radial head were identified. These fragments were removed from the medial and anterior aspects, and the medullary canal of the radius was identified. The radial head fragments were then reduced on the Mayo table.

The impossibility of anatomically reducing the radial head fragments and lack of congruence over the entire surface were evident, which limited the attempt to fix it with an anatomical plate. Therefore, the initial plan was executed intraoperatively, placing a bone cement spacer on the radial head according to surgical technique (Figure 4).

Precise diameters are crucial for correctly constructing the spacer. Reducing the radial head fragments is extremely useful because it allows us to replicate the original radial head’s height and diameter. This mold, similar in height and diameter to the head, is then filled with cement, creating a concave surface, a technique similar to the one previously published by Barati et al [11] (Figure 5).

The decision to proceed with cemented spacer placement was guided not only by the lack of a prosthesis but also by a thorough intraoperative assessment of elbow stability. Integrity of the lateral ulnar collateral ligament (LUCL), annular ligament, and anterior capsule was confirmed and repaired as needed.

The anterior capsule was repaired using a transosseous suture in the ulna with fiberwire, followed by the repair of the annular ligament and lateral collateral ligament to provide adequate stability. Finally, varus-valgus stress testing and posterolateral rotatory stability were evaluated intraoperatively, ensuring that the elbow remained stable without immediate need for a definitive implant (Video 1).

POSTOPERATIVE OUTCOMES:

Currently, after a follow-up of 21 months, the patient is asymptomatic and independent. In the clinical assessment the following elbow mobility arcs were found: flexion 80°, extension −25°, pronation 10°, and supination 80°. Functional scales were used, where she presented a score of 27.5 in Disabilities of the Arm, Shoulder and Hand (DASH) and 95/100 in the Mayo Elbow Performance Score (MEPS), considered an excellent result above 90 points (Table 1).

A radiological control was also performed, where an adequate position of the cemented spacer was observed, with no migration or fatigue. Possible complications include bone lysis in the region proximal to the spacer (Table 2).

Chanlalit et al reported a rate of 57.5% of osteolysis (RNO), usually at the radial neck, with different types of implants (prosthesis), and a systematic review by Heijink et al reported a rate of 17% overall but 50% on uncemented press-fit implants [12,13]. The pathophysiology remains unclear [14], as do risk factors. Likewise, data are sparse regarding the impact of RNO [15]. This complication and the risk of osteolysis in other anatomical sites attributable to the spacer components are potential adverse outcomes that could occur in this patient.

Discussion

COMPARISON OF TREATMENT OPTIONS:

Comparing RCR and ACR, a retrospective study by Lópiz et al [19] concluded that RCR showed better functional outcomes and fewer complications than ACR. Antuña et al [20] reported good long-term results of RCR in radial head fractures in 26 young patients. Scoscina et al [4] found significantly better outcomes were achieved in supination with ACR (P=0.031).

Clinically, patients in both groups had satisfactory scores without statistically significant differences, despite the younger age in the ACR group (mean 53.9 vs 64.5 years in the RCR group). Additionally, the operation time for RCR was shorter compared to the other 2 groups. On the contrary, when comparing ORIF and ACR results, Ikeda et al [21] recommended ORIF due to stiffness and poorer functional scores in the RCR group.

Radial head resection has traditionally been indicated for fractures with no associated instability in older patients with low function. Jansenn et al [22], in a retrospective study of acute Mason 3 fractures treated with RCR and followed up for 30 years, found excellent results in up to 80% of cases in clinical and functional assessments. However, Josefsson et al [23] reported a high incidence of osteoarthritis (OA) (up to 63%) and recurrent instability after more than 30 years of follow-up.

With the advent of radial head arthroplasty (ACR), the use of RCR has declined. The radial head serves as a secondary stabilizer in significant valgus, and biomechanical studies have shown that RCR alters normal elbow kinematics, leading to inadequate load transfer and clinical instability, necessitating radial head replacement.

Radial head arthroplasty is indicated in cases of displaced, irreparable fractures of the radial head and fractures of the radial head associated with elbow dislocation or significant ligamentous injury [24,25].

Since 2000, numerous anatomical studies have biomechanically evaluated various radial head prostheses from a functional perspective concerning existing anatomical variations of the radial head. Anatomical designs were developed; however, the precise placement of the implant remains crucial to achieve proper alignment, regardless of the prosthetic design [1].

Regarding the different prosthesis designs, a review by Heijink et al [26] analyzed various radial head prosthesis and identified 30 publications involving 727 patients. The overall outcome was good in 85% of them, and revisions and functional outcomes were not dependent on design factors such as polarity, material, or technique (cemented or press-fit). The only notable finding was that silicone implants consistently had poor results.

Many studies have reported complications in the treatment of complex injuries with radial head replacement (RCR), like vertical instability with migration of the radius, dislocation, increased valgus, humerocubital arthritis, reduced grip strength, and cubital neuropathy [27,28].

However, in the series by Scoscina et al, only 2 patients (12.5%) treated with RCR were subjected to revision due to instability under valgus forces. Additionally, other surgical treatments like open reduction and internal fixation (ORIF) can present complications such as non-union and arthritis when performed on inappropriate candidates [29], with reported rates as high as 50%. Therefore, there is a higher rate of surgical revision among patients treated with ORIF compared to those treated with anatomical or radial head replacement (ACR and RCR) [4].

Radial head replacement for Mason 3 fractures has better clinical outcomes and patient satisfaction. Therefore, anatomical radial head replacement (ACR) may be preferable for young patients and/or those with significant functional demands. The resection group also had good results, with shorter surgery time compared to other techniques, although supination was worse compared to ACR.

Due to the shorter surgical time, radial head excision (RCR) is indicated for older patients with lower functional demand. With open reduction and internal fixation (ORIF), results are affected by the high comminution and the risk of vascularization loss, leading to increased stiffness and high rates of revision surgery [4]. It is not surprising, therefore, that a recent survey conducted by Mahmoud et al [9] among 49 surgeons revealed that only 4.1% of decisions were based on scientific evidence.

Injury of the LUCL (lateral ulnar collateral ligament), LCM (medial collateral ligament), and the coronoid process are contraindications for radial head replacement (RCR) because they can lead to instability under valgus stress and posterior-lateral instability demands. Similarly, concomitant injury to the interosseous membrane causes migration with axial instability of the forearm. This has implications in the distal radioulnar joint, causing progressive wrist pain and functional deterioration [17].

Alexander et al reported that in 727 patients, there was a clear indication for RCR. The most common reason for acute resection of the radial head (n=347) was an isolated comminuted fracture of the radial head, with most (52%) being Mason type III fractures [30]. This aligns with the circumstances described in this case.

Radial head replacement (RCR) can alter the kinematics of the elbow and increase varus-valgus laxity, even when ligaments are intact [31]. Additionally, comminuted fractures of the radial head can also be accompanied by hidden ligamentous or intra-articular injuries, which can lead to early degenerative osteoarthritis of the ulnohumeral joint, increased valgus angulation of the elbow joint, and secondary ulnar nerve discomfort [32].

Alexander et al found various issues in 22 out of 27 studies. Radiographic degenerative changes of the elbow (n=82) were the most frequent complication, followed by positive ulnar variance (n=50), periarticular ossification (n=46), and radiocubital subluxation (n=30) [33].

The absence of associated injuries to other stabilizers allows us to delay surgery long enough to ensure the placement of a definitive implant, typically without the use of a temporary spacer. Although the indications for using a temporary spacer and a metal prosthesis are identical, the use of the former is justified by the need to reconstruct an unstable elbow in situations where the definitive implant is not available [17].

The choice between radial head fixation and arthroplasty is typically straightforward for simple fractures or highly comminuted fractures. However, it becomes more complex for fractures that fall within the middle range of complexity. Patient age may influence the decision between radial head arthroplasty (RHA) and open reduction and internal fixation (ORIF).

While studies have reported outcomes of radial head replacement with an average patient age under 50, the age ranges in these studies are broad, and outcomes vary significantly across age groups. As a result, treatment decisions should consider more narrowly defined age brackets.

A survey by O’Connor et al involving 150 surgeons examined preferences for treating radial head fractures in various clinical scenarios. The findings suggested that surgeons tend to favor ORIF over RHA for younger patients. However, whether this preference aligns with evidence from the literature remains unclear. Gaining a better understanding of clinical outcomes for radial head replacement in younger adults could help refine treatment strategies.

A recent meta-analysis reported by Hains et al [34] with 5 RCTs (326 patients) included radial head arthroplasty (RHA), open reduction internal fixation (ORIF), and nonoperative management. Showing that in displaced radial head fractures, RHA is associated with significantly better functional PROMs than ORIF based on the evidence available. Nonoperative management has not been shown to be significantly worse.

In the present case, the extension and flexion range of motion differed from the expected normal parameters. However, this limitation is attributable to the temporary use of a cemented spacer, necessitated by the unavailability of a radial head prosthesis, which is the definitive treatment. The cemented spacer was intended to maintain joint space and stability, prevent soft-tissue adhesions, and preserve partial elbow function while awaiting definitive reconstruction. Given the mechanical constraints of the spacer, the restricted range of motion was anticipated and was considered an acceptable interim outcome to minimize further articular deterioration and optimize the eventual surgical conditions.

The use of a spacer has demonstrated adequate tolerance and mechanical strength. Despite its utility and low complication rate, this method should not be considered a systematic alternative to current prosthetic treatment. It remains a useful resource for resolving complex situations when a definitive implant is unavailable, but patients should be aware of the temporary nature of the spacer. In this case, the use of the cemented spacer was extended due to difficulties in obtaining a radial head prosthesis. Nevertheless, ongoing clinical and radiographic evaluations demonstrated satisfactory patient progress and appropriate radiological preservation, with no apparent complications. Consequently, it was deemed appropriate to temporarily maintain this provisional treatment.

Compared to standard radial head prostheses, temporary cement spacers offer a valuable, although imperfect, alternative in resource-limited scenarios. While prosthetic replacements are biomechanically superior in restoring normal joint kinematics and preventing long-term degeneration, their immediate availability is not guaranteed in all clinical settings. This case demonstrates that a cement spacer can successfully preserve joint space, maintain partial functionality, and prevent severe instability over a prolonged period.

The literature primarily focuses on prosthetic solutions; few studies have systematically evaluated the outcomes of temporary spacers in elbow reconstruction. As such, this report contributes to a growing body of evidence suggesting that, although not ideal for definitive management, cement spacers may represent a viable interim solution when prostheses are unavailable. Future research should aim to characterize the long-term mechanical behavior, complication rates, and functional outcomes associated with this approach, particularly in settings where access to specialized implants is limited.

Although the patient’s outcome was favorable, it is important to acknowledge potential biases and confounding factors that may limit the generalizability of these results. The relatively young age and absence of significant comorbidities in this patient likely contributed to her excellent recovery and may not reflect outcomes in older or medically complex populations. Additionally, the specific mechanism of injury, the prompt surgical intervention, and the consistent follow-up care may have positively influenced the clinical course.

In contrast, prior studies have reported higher complication rates and functional limitations with temporary spacers, particularly in patients with associated ligamentous injuries or delayed interventions. Therefore, while this case report supports the viability of a cement spacer as a temporary solution, broader conclusions must be drawn cautiously. A comparison of clinical outcomes and complications between the present case and prior studies on radial head fracture management is presented in Table 3.

This comparison highlights the need for more research to better define the indications, limitations, and long-term outcomes associated with temporary cement spacers, particularly in resource-limited settings or emergency situations where definitive implants are not immediately available. Although this case report does not propose a new indication for cement spacer use, it demonstrates its viability as an interim solution when definitive implants are not available, provided that soft-tissue stability is assured. Further research involving larger cohorts and diverse patient populations is needed to validate these findings and refine patient selection criteria.

Conclusions

The indications for radial head replacement are well established and remain undisputed. In complex injuries where anatomical repair or stabilization with ORIF is not feasible, radial head replacement is necessary. In such cases, we opted for a temporary spacer to maintain stability and prevent residual dislocation or radial elevation.

Our goal was to use an easily available material capable of controlling valgus and axial forces. Given its temporary nature, the spacer should be removed or replaced with a definitive implant. Further high-quality randomized controlled trials are needed to define optimal treatment strategies and establish evidence-based international consensus.