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Radial head arthroplasty

117 citationsUpdated Oct 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Radial head arthroplasty serves as a reliable procedure for complex radial head fractures not amenable to reconstruction, particularly when associated with unstable elbows or forearm injuries, provided concomitant injuries are addressed [11]. Clinical outcome studies indicate that head replacement is a reasonable option for patients with comminuted radial head fractures and complex elbow trauma [1]. The experience with monoblock metallic implants has encouraged continued utilization for unreconstructable fractures [4], while pyrocarbon radial head implants represent a viable alternative [39]. Better outcomes are reported for radial head arthroplasty in terms of elbow stability, range of motion, pain, and fewer complications compared to radial head excision [45]. However, radial head resection is preferable if the elbow is stable due to being less demanding and cheaper, while replacement is recommended for unstable elbows [74].

Metallic radial head arthroplasty yields satisfactory results in acute unreconstructable fractures or as a salvage procedure for previously treated fractures [9]. The medium-term outcome of metallic radial head arthroplasty is encouraging [12], and the overall midterm outcome of a series of 30 press-fit bipolar radial head arthroplasties can be considered favorable [150]. Modular radial head arthroplasty showed promising findings in short to midterm results for comminuted fractures [17]. Radial head replacement appeared to reach better outcomes in patients with Mason type III radial head fractures followed 5 years or less [27]. Patients report excellent Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups, despite any need for reoperation [25].

Long-term outcomes for radial head arthroplasty are satisfactory; however, there is a high complication and revision rate [54]. Survival rates with uncemented implants remain high at 10 years [25], with implant survival at 75.1% at 18 years and the highest annual failure rate observed in the first postoperative year [54]. Radial head arthroplasty for fractures has a high potential for reoperation within the first year [25]. A secondary radial head prosthesis and a worse clinical outcome (MEPS < 85 points) significantly increase the risk of not returning to sports after radial head arthroplasty [23]. Longer-term studies will be required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening [8]. The reproducibility of results would be improved by using a minimum follow-up of three years combined with a consensus of the definition of the reasons for failure after radial head arthroplasty [6].

Anatomy & Pathophysiology

Bony Anatomy

The radial head is disk-shaped with a greater diameter than the neck [96]. It possesses a shallow cuplike surface that articulates proximally with the capitellum and medially with the radial notch of the ulna [96]. The biceps muscle inserts on the tuberosity of the radial head, located immediately distal to the neck [96]. The radial head is neither completely round nor completely cylindrical [125]. This non-cylindrical shape permits a proximal-distal pistoning effect of the radius during forearm rotation and guides the supination-pronation arc [125]. The radial head has a slightly elliptical cross section and interdigitates precisely with both the lesser sigmoid notch and the lateral lip of the trochlea [114]. The proximal radius exhibits a slight angulation with respect to the shaft, which complicates attempts to reconstruct or replace the radius [114]. The radial head is seated in the lesser sigmoid notch and has axial contact with the capitellum of the distal humerus [63]. The secondary ossification center of the proximal radius appears as a small sphere between the third and fifth years of life and fuses with the shaft between the ages of 16 and 18 years [96]. The entire radial head is covered with articular cartilage, meaning the blood supply to the epiphysis is supplied through the more distal metaphysis [96]. The radial head has a relatively small nonarticular surface, requiring implants placed on the articular surface to be countersunk [114]. The nonarticular area of the radial head can be determined as an arc of roughly 90 degrees with its midpoint directly lateral with the arm in neutral position [114]. The vascular supply to the radial head is limited and tenuous [114].

Ligaments and Stability

The radial head serves as a secondary stabilizer of the elbow [31]. The primary stabilizers of the elbow are the medial collateral ligament (MCL) and the lateral ulnar collateral ligament (LUCL) [125]. The radial head contributes considerably to the neutralization of valgus forces across the elbow, which occur in the axially loaded, fully extended elbow [125]. An intact radial head, or its substitute, can unload an injured MCL, allowing the ligament to heal without formal repair in most instances [125]. The radial head, along with the LUCL, can prevent posterolateral rotatory instability [125]. The buttressing effect of the radial head prevents the proximal migration of the radius when interosseous membrane injury is present, as seen in Essex-Lopresti-type injuries [125]. The radial head is the secondary restraint to valgus stability of the elbow [63]. The ligaments have the most marked influence on elbow stability, particularly when the upper limb is positioned such that valgus and varus gravity loads are applied [113].

Injury Mechanisms and Pathophysiology

Radial head fractures typically result from a fall on an outstretched hand with the forearm in pronation, which results in an axial load on the elbow [31]. Radial head fractures are generally caused by longitudinal loading from a fall on an outstretched hand [63]. Dislocation of the elbow is another cause of radial head fractures [63]. A valgus load causes impaction of the radial head into the capitellum, commonly with rupture of the MCL [118]. Posterolateral rotatory subluxation of the radial head with respect to the capitellum causes a partial articular shear fracture of the anterior portion of the radial head, often with rupture of the LCL [118]. An axial forearm load causes impaction of the radial head into the capitellum, with more severe trauma producing a fracture of the coronoid or rupture of the interosseous membrane and distal radioulnar joint ligaments [118]. The so-called Essex-Lopresti injury involves longitudinal disruption of the interosseous membrane, distal radioulnar joint injury, and radial head fracture or dislocation [63]. Fractures of the radial head or neck may occur as a result of dislocation of the elbow [96]. The radial neck may be fractured by impact against the inferior aspect of the capitellum at the time of posterior dislocation or at the time of spontaneous reduction [96]. A radial head fracture may also occur with anterior dislocation of the elbow and produce anterior displacement of the head [96].

Biomechanics and Kinematics

Fractures of the radial head cannot be treated by simple excision without altering the basic kinematics of the elbow joint [92]. Changing the length of the radial neck significantly alters the kinematics of the elbow [90]. Lengthening the radial neck by 2.5 mm or more forces the ulna into a more varus and externally rotated position even with the application of valgus stress [90]. Shortening the radial neck by 2.5 mm or more causes the ulna to track in a valgus and internally rotated position [90]. Shortening the radius by 2.5 mm or more causes increased total laxity of the elbow [90]. Altered elbow kinematics or maltracking of the ulno-humeral joint due to altered radial neck length could induce degenerative disease due to abnormally high stresses on the cartilage [90]. The kinematics of the elbow joint deviated increasingly from the native joint kinematics with a +2 mm to a +4 mm radial overlengthening [89]. The kinematics of the elbow deviated increasingly from those of the native joint with a 2 mm to a 4 mm lengthening of the radius [91]. Restoration of the anatomic radial head height is critical when performing radial head arthroplasty to maintain normal joint biomechanics [24]. Proper balancing and adequate bone resection from the radial head is mandatory for obtaining normal elbow kinematics during the radial head arthroplasty procedure [101]. There were only submillimetre kinematic changes and small changes in joint pressure and interosseous membrane tension after the insertion of a radial head arthroplasty in an experimental setting [2]. The kinematics of the radiocapitellar joint are different after bipolar arthroplasty than in the normal elbow, with abnormal positioning of the prosthetic radial head in supination and evidence of insufficient intraprosthetic motion [109]. A few degrees or mm changes in elbow kinematics could potentially increase stress to the interosseous membrane and contact pressure within the joint [93]. The radial head prosthesis mimics the mechanics of the native radial head in terms of mean contact area, mean contact pressure, and peak contact pressure [133]. Different patterns of contact pressure and area curves during elbow flexion-extension were observed between the native radial head and anatomic radial head prostheses [133]. There were no statistical differences in radiocapitellar joint contact mechanics as measured by 3-dimensional joint congruency among three implant geometries in cadaveric specimens undergoing continuous simulated forearm rotation [132]. The radiocapitellar gap is significantly smaller under load during elbow flexion compared with extension [200]. Treatment of the Essex-Lopresti lesion with a radial head replacement alone prevents proximal migration, but does not restore normal forearm biomechanics [131].

Implant-Host Interface and Sizing

The commercially available metallic radial head design may overestimate the dimensions of the radial neck [99]. Inadequate sizing of the radial head implant may lead to an inadvertent change in proximal radial length with potentially adverse effects on elbow, forearm, and wrist mechanics [99]. In all patients in whom the radial neck could accommodate a prosthetic stem, an average shortening of 4 mm (range 1-7 mm) would occur if a commercially available prosthesis were used [90]. The anatomical parameters of the proximal radius of each case and the radial head implant specifications should be assessed when selecting a radial head implant [41]. A single component would suffice for right and left elbows, but a perfectly conforming prosthesis is practically impossible due to large variations in normal anatomy [146]. The native radial head is somewhat elliptical and is offset relative to the radial neck [83]. Most commercially available implants are axisymmetric and nonanatomic [83]. The optimal implant diameter is typically the minor diameter of the elliptical native radial head, most commonly 2 mm smaller than the maximum diameter [83]. An implant whose diameter is too large may cause an erosion of the lateral trochlea, prevent optimal closure of the annular ligament, and may contribute to residual instability [83]. Overlengthening (overstuffing) with the placement of a radial head prosthesis that is too thick may be associated with the development of pain, stiffness, and capitellar wear [83]. Radial head implant maltracking causes premature capitellar cartilage wear, pain, limited rotation, and may contribute to loosening of fixed stem prostheses [83]. Radiographic parameters are not very useful to detect overlengthening of the radial head [83]. The medial ulnohumeral joint space should be parallel; overlengthening causes the medial ulnohumeral joint to open laterally [83]. Overlengthening of the radial head insert may not be evident on radiographs until there is 6- to 8-mm overlengthening [83]. A nonparallel medial ulnohumeral joint space may suggest overstuffing, but comparing radiographs of the uninjured elbow is the best investigation when overstuffing is suspected [149]. The bicipital tuberosity and distal radius are unreliable landmarks for radial head implant alignment [156]. The measured landmarks show no consistent rotational relationship with the maximum diameter of the radial head [156]. Oversizing the radial head may "stabilize" the elbow by placing the entire lateral soft tissue complex on tension, but this is an error [77]. Oversizing the radial head may cause capitellar arthrosis and pain [77]. The reconstructed articular surface should end up no more than 1 mm proud of the visible proximal corner of the lesser sigmoid notch [77].

Classification

Mason: Mason classified radial head fractures into three types based on displacement and comminution [42]. Type I fractures are non-displaced marginal fissures or fractures [186]. Type II fractures are displaced marginal fractures with separation or impaction, where the fragment constitutes ≥ 30% of the articular surface and is displaced by ≥ 2 mm [42, 186]. Type III fractures are displaced comminuted fractures involving the entire radial head [186].

Broberg and Morrey: Broberg and Morrey refined the Mason classification by adding a Type IV, defined as a radial head fracture combined with elbow dislocation [186]. They also specified that for a fracture to be considered Type II, the fragment must constitute ≥ 30% of the articular surface and be displaced by ≥ 2 mm [42].

Hotchkiss: Hotchkiss modified the Mason classification to better guide surgical decision-making [186]. In this modification, Type II is defined as a displaced fracture of the radial head or neck combined with mechanical blocking of joint motion or loss of joint congruity [186]. Type III is defined as comminution that precludes internal fixation and requires either resection or prosthetic replacement of the radial head [186].

Mayo Clinic: The Mayo Clinic classification addresses the limitation of the Mason and Broberg-Morrey systems by incorporating concomitant lesions, which are present in nearly 80% of multi-fragment fractures [186]. In this system, the radial head fracture is described using Mason’s classification, with letters added to indicate concomitant lesions [186]. Upper case letters indicate a lesion that is treated, while lower case letters indicate a lesion that is untreated [186].

Other Considerations: The Mason and Broberg-Morrey classifications have poor intra-observer and inter-observer reproducibility [186]. Treatment decisions for radial head fractures are often guided by the Mason-Hotchkiss classification [50]. Non-surgical treatment is preferred for Mason type I fractures [50]. For Mason type II fractures, either conservative treatment or open reduction and internal fixation may be appropriate [50]. Open reduction and internal fixation is typically used for Mason type III fractures with three or fewer fragments [50]. Arthroplasty is usually reserved for highly comminuted fractures with extensive fragmentation [50]. Recommendations for surgical treatment of radial head and neck fractures according to the Mason classification can now be given with the best available evidence [84].

Clinical Presentation

Radial head fractures typically result from a fall on an outstretched hand with the forearm in pronation, resulting in an axial load on the elbow [31]. Approximately 20% of all elbow fractures involve the radial head [31]. These injuries often are associated with more complex injuries, including associated elbow fractures, dislocations, and soft-tissue injuries [31]. Of patients with radial head fractures, 30% have other soft-tissue and skeletal injuries, including carpal fractures, distal radioulnar joint (DRUJ) and interosseous membrane disruption, coronoid fractures, Monteggia fracture-dislocations, capitellar fractures, and medial and lateral collateral ligament injuries [31]. The radial head plays an important role as a secondary valgus stabilizer of the elbow [31].

History and Inspection: Lateral elbow pain and tenderness or limitation in elbow or forearm motion should alert the examiner to the possibility of a radial head fracture [31]. The patient should be questioned carefully about concomitant wrist, forearm, or shoulder pain [31].

Palpation and Range of Motion: The surgeon should examine the forearm, wrist, and elbow for tenderness along the course of the interosseous membrane (Essex-Lopresti lesion), instability of the DRUJ, pain at the medial side of the elbow (medial collateral ligament [MCL]), and pain at the lateral side of the elbow (lateral collateral ligament [LCL]) [31]. There is no evidence that examination for a bony block to forearm rotation is reliable or accurate, as it is difficult to distinguish reluctance to move the forearm as a result of pain or a true mechanical block [42]. A few patients with full forearm rotation have palpable crepitation over the radial head with forearm rotation, but it is not clear if this is associated with greater discomfort or impairment in the long-term [42]. Aspiration of the intra-articular hematoma and injection of a local anesthetic can be helpful when assessing mechanical blocks to motion [31]. A study of 16 non-displaced radial head fractures found that aspiration reduced articular pressure and provided pain relief (from 5.5 to 2.5 on a 10-point visual analogue scale) [42].

Imaging and Diagnostic Findings: AP and lateral radiographs of the elbow are routinely obtained for radial head fractures [31]. The radiocapitellar view is accomplished by positioning the patient as for a lateral view but angling the tube 45° toward the shoulder [31]. A proportion of radial head and neck fractures are not visible on standard anteroposterior and lateral radiographs of the elbow and are referred to as ‘occult’ fractures [42]. In patients with occult radial head fractures, there is tenderness over the radial head and anterior displacement of the fat pad by haemarthrosis on a lateral radiograph [42]. Nondisplaced fractures of the radial head may be diagnosed by elevation of the anterior and posterior fat pads (the sail sign) by an intra-articular hemarthrosis [31]. For comminuted fractures, CT can delineate the location, number, and size of the fragments and is rapidly emerging as a standard imaging method for more complicated radial head fractures [31].

Investigations

Preoperative Imaging and Assessment

Plain radiography: Nondisplaced radial head fractures may be diagnosed by elevation of the anterior and posterior fat pads (the sail sign) caused by intra-articular hemarthrosis [31]. The radial head arthroplasty diameter can be predicted preoperatively in two-thirds of cases from a simple measurement of the humeral condyle diameter with an appropriate lateral view of a simple radiograph [32].

CT: CT can delineate the location, number, and size of fragments and is rapidly emerging as a standard imaging method for more complicated radial head fractures [31]. CT scans are useful to rule out subtle coronoid fractures that may necessitate operative intervention in the setting of radial head fracture with associated ulnar-humeral dislocation [77].

Other Considerations: The surgeon should examine the forearm, wrist, and elbow for tenderness along the course of the interosseous membrane, instability of the distal radioulnar joint, and pain at the medial or lateral side of the elbow to identify concomitant injuries [31]. Radial head diameter measurements showed excellent reliability, suggesting that the excised radial head, when available, should be used to select the implant diameter [188].

Intraoperative Assessment

Fluoroscopy: The stability of the elbow and forearm should be evaluated fluoroscopically with varus, valgus, rotational, and axial stress tests before and after radial head excision [29]. A radial head arthroplasty should be available for use if the elbow is determined to be unstable in any plane during fluoroscopic evaluation [29]. Intraoperative visualization of a gap in the lateral ulnohumeral joint is a reliable indicator of overlengthening following the insertion of a radial head prosthesis [174].

Prosthetic Positioning: The arthroplasty should articulate at the height of the proximal radioulnar joint, about 2-mm distal to the coronoid [137]. Prosthetic radial head height appears 2.2 ± 0.4 mm more proximal than the coronoid lateral edge on anteroposterior fluoroscopy when the articular surface is even with the coronoid [87]. The medial ulnohumeral joint space should be parallel on an anteroposterior fluoroscopic view to confirm that the prosthesis is neither too thick nor too thin [137]. The lateral ulnohumeral joint space is often wider than the medial ulnohumeral joint radiographically so it cannot be used to evaluate prosthesis thickness unless a contralateral radiograph is available [137].

Advanced Measurement: The radiographic measurement method of Athwal et al. can be used to estimate and diagnose the magnitude of overlengthening of the MoPyC radial head prosthesis, although sensitivity is limited (76%) for small overlengthening of 1.5 mm [192]. A 3D evaluation technique seems to provide an accurate and precise method for assessing prosthesis placement in radial head arthroplasty with minimal measurement errors [181].

Postoperative Imaging and Radiographic Findings

Plain radiography: There is a positive association between radiographic findings and patient symptoms for postoperative complications after radial head arthroplasty, validating radiography as the preferred postsurgical modality of imaging [19]. Anatomic radial head replacement has a risk of radiographic technical mistakes that correlate to poorer outcomes [35]. Proximal radial neck resorption (PRNR) after press-fit radial head arthroplasty is a common radiological finding that develops in the first 24 months before stabilizing definitively [66].

Limitations: Neither radiographic landmark is sufficiently reliable to adequately assess radial head prosthetic overlengthening [135]. Postoperative radiographs are unreliable when evaluating prosthesis thickness [137].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, or pharmacologic interventions. The text primarily addresses surgical indications and outcomes following failed non-operative management or unreconstructable fractures.

Operative

Indications: Radial head arthroplasty is the established treatment for unreconstructible Mason type III and IV fractures [194] and is indicated for unreconstructable radial head fractures [4]. It serves as a reasonable option for patients with comminuted radial head fractures and complex elbow trauma [1]. In the setting of an irreconstructable radial head and neck fracture, arthroplasty is an excellent option for restoring radiocapitellar contact and elbow stability [43]. For fractures with three or more articular fragments or those not amenable to stable internal fixation, excision of the radial head and prosthetic replacement using monopolar, metallic radial head implants with modular components and a smooth neck is preferred [129]. The procedure is recommended for unstable elbows, whereas radial head resection is preferable if the elbow is stable [74]. Although radial head resection could be a valid treatment in complex elbow dislocations, radial head arthroplasty remains the main option for the treatment of these lesions [21]. Concomitant elbow fractures or dislocations do not affect the longer term outcomes of patients with unreconstructable radial head fractures requiring radial head arthroplasty [169]. Younger patients should be counseled regarding the increased risk of requiring further surgery after radial head replacement [15]. A modular metallic radial head arthroplasty system should always be available when operating on displaced radial head fractures because comminution is often more severe than predicted by plain radiographs or CT [121]. The intraoperative decision to fix or replace the radial head is critical to optimize treatment outcomes [71].

Surgical Approach / Technique: The radial head can be accessed with the arm across the patient's body or with the arm extended on a radiolucent hand table [141]. A lateral or posterior-based incision is utilized for radial head arthroplasty [141]. Specifically, a straight lateral approach is taken to access the radial head directly through the epicondylar muscle, or the Kocher approach is taken between the anconeus and the extensor carpi ulnaris [199]. An incision is made into the capsule anterior to the lateral ulnar collateral ligament through the annular ligament to expose the lateral side of the joint without violating the lateral ulnar collateral ligament [199]. The proximal third of the annular ligament should be isolated and sharply cut to expose the radial head [141]. The annular ligament must be sectioned to adequately expose the radial head and neck and to facilitate the prosthesis insertion [83]. The forearm should be maintained in pronation during approach to protect the posterior interosseous nerve [51]. Aggressive anterior and medial retraction should be avoided to prevent posterior interosseous nerve injury [51]. Dissection distal to the biceps tuberosity should be avoided to prevent posterior interosseous nerve injury [51]. The radial neck can be delivered with a bump under the elbow or with a carefully placed baby Hohmann retractor [141]. The radial neck should be delivered atraumatically, avoiding forced retractor placement behind the neck [51]. All fragments should be removed and then assembled on the back table for sizing [141]. The size of the radial head prosthesis is selected by comparing the excised radial head fragments [199]. The size of the radial head diameter and thickness should be measured and the implant downsized from the measured size [51]. A fresh saw cut at the junction of the head/neck or at the level of the fracture is made to create a stable, straight base [141]. Thorough irrigation is recommended to remove all bony debris to minimize risk of heterotopic ossification [141]. The canal can be prepared with a canal finder and subsequent rasps as per the manufacturer guidelines [141]. If a smooth stem prosthesis is to be used, choose a stem 1 mm smaller than the maximum-sized diameter neck rasp to allow the stem to move slightly in the neck [83]. After placing trial implants, the proximal edge of the prosthesis should sit no more than 1-mm proximal to the corner of the lesser sigmoid notch of the coronoid [141]. After placing trial implants, the radial head should articulate at the level of the proximal radial ulnar joint which is typically 2 mm distal to the tip of the coronoid [83]. The head must reach the limit between the trochlear notch and the radial notch of the ulna [199]. Any distraction or angulation at the lateral ulnohumeral joint indicates overstuffing [141]. A range of motion test and a stability test with manual varus and valgus stress at the elbow in extension should be performed after trial implantation [141]. Stability examination should be performed with trial as well as final implant [51]. A careful evaluation for congruent tracking of the radial head implant on the capitellum both visually and fluoroscopically is required [83]. If the radial head implant is not tracking optimally with the capitellum during forearm rotation, downsize the stem diameter of a smooth stem implant or reposition the stem of a fixed stem implant to correct this [83]. The relationship of the implant to the proximal radioulnar joint and the coronoid should be evaluated radiographically [51]. Fluoroscopic evaluation of the ulnohumeral joint should be performed to avoid gapping [51]. Following implantation of the final prosthesis, the annular ligament and any concomitant ligamentous injuries should be addressed [141]. The lateral ligament complex is repaired with a suture anchor, if possible, to ensure adequate repair of the ulnar fascicle of the lateral collateral ligament [199]. The annular ligament is closed after impacting the final components [199]. In most elbows, stability will be restored with placement of a radial head and repair of the lateral complex [5].

Implant Selection: Due to the variety of implant designs and limited evidence, current data provide no evidence for a specific radial head prosthesis design [46]. Implant fixation type does not appear to affect functional outcomes of radial head arthroplasty [30]. If a radial head prosthesis is used, prosthesis oversizing should be avoided as it may contribute to worse outcome with other radiographic abnormalities [36]. The study demonstrates significant radiographic differences between two frequently used radial head arthroplasty implants regarding radial neck dilatory remodeling [10]. It was not possible to consistently insert radial head prostheses anatomically in an in vitro study [49]. None of the prostheses functioned as well as the native radial head, suggesting that open reduction and internal fixation to restore radial head anatomy is preferable to replacement when possible [75]. The native radial head is elliptical in shape and offset relative to the radial neck [162]. A bipolar radial head prosthesis may be relatively contraindicated in patients with, or at risk for, persistent elbow instability due to the potential for component dissociation [126]. Surgical implantation of personalized radial head prosthesis produced with 3-dimensional printing technology is a treatment modality with easy application, short operating time, and good functional results [104]. A partial radial head replacement could be accurately aligned to remaining landmarks as a method to restore elbow anatomy and stability in fractures involving only a portion of the articular surface [18]. Performing capitellar resurfacing arthroplasty at the time of metallic radial head arthroplasty should be considered when capitellar bone quality is poor [47].

Other Considerations: The review aims to shed light into overlengthening as a complication of radial head replacement and to help identify and treat it [20]. Overstuffing of the joint should be avoided to prevent stiffness [51]. Early motion is recommended to prevent stiffness [51].

Complications

Implant Failure and Mechanical Complications: Implant loosening, breakage, and subluxation were observed in 4, 2, and 2 patients, respectively, within a cohort where almost 40% experienced complications during follow-up [97]. The risk of revision is directly correlated with implanted radial head diameter [57]. Individuals who did not undergo a revision by 3 years tend to retain the implant [57]. A secondary radial head prosthesis significantly increases the risk of not returning to sports after radial head arthroplasty [23]. A worse clinical outcome (MEPS < 85 points) significantly increases the risk of not returning to sports after radial head arthroplasty [23]. The highest annual failure rate for monopolar radial head replacement is observed in the first postoperative year [54]. Implant survival for monopolar radial head replacement is 75.1% at 18 years [54]. Survival rates with uncemented implants remain high at 10 years, despite a high potential for reoperation within the first year [25]. The study demonstrates an excellent survival of press-fit radial head arthroplasty of 92.1% at 10 years [204]. Bipolar and press-fit radial head arthroplasty gives unsatisfactory mid-term outcomes in the treatment of acute fractures of the radial head or their sequelae [70]. Failure of primary radial head replacement may be due to infection, peri-prosthetic fracture, implant loosening, dislocation, dis-assembly, heterotopic ossification or persistent pain [170]. Stress shielding may be observed with press fit designs but has not been shown to lead to implant failure [170]. Surgical factors that predispose to early failure include over-stuffing, improper alignment, inadequate fixation or persistent instability [170]. Persistent instability may be due to inadequate soft tissue repair or inadequate management of an associated ulna fracture [170]. Hospital factors, implant factors and patient factors that can lead to reoperation include the use of a silicone implant, younger age, fewer co-morbidities and delay to surgery [170]. The best estimate for revision rate of radial head arthroplasty is 2 per 100 person years of follow-up [170]. Longer-term studies are required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening [8].

Radiographic and Biomechanical Complications: There is a positive association between radiographic findings and patient symptoms for postoperative complications after radial head arthroplasty [19]. Radiography is validated as the preferred postsurgical modality of imaging for detecting complications after radial head arthroplasty [19]. Significant radiographic differences exist between two frequently used radial head arthroplasty implants, including radial neck dilatory remodeling with an uncemented, press fit, fully chemically etched stem design [10]. Overlengthening is a complication of radial head replacement [20]. RHA results in modest complication and revision rates at long-term follow-up, despite high levels of radiologic degenerative changes over the same period [208]. Secondary osteoarthritis after resection of the radial head is a concern, but it did not affect the functional outcome during the follow-up time in Mason-IV fracture dislocation cases [38].

Neurologic and Soft Tissue Complications: The incidence of neurologic complications associated with the surgical treatment of complex elbow fractures requiring implantation of a radial head prosthesis may be underestimated in the literature [76]. In a series of pyrocarbon unipolar radial head prostheses, 2 patients had postoperative nerve palsies: 1 radial deficit and 1 ulnar nerve deficiency [142]. One patient required radial neck banding for a nondisplaced intraoperative fracture during impaction of the prosthesis in a series of pyrocarbon unipolar radial head prostheses [142]. Ongoing severe joint stiffness was the most common complication in a cohort where almost 40% of patients experienced complications [97]. Surgical arthrolysis was performed in 7 patients for ongoing severe joint stiffness in a cohort where almost 40% of patients experienced complications [97]. Patients with failed radial head implants report an average extension lag of 30 degrees [170]. Patients with failed radial head implants report flexion up to 117 degrees [170]. Patients with failed radial head implants report pronation from 58 degrees to 52 degrees supination on average [170].

Silicone Implant Specific Complications: Silicone radial heads were found to be severely worn in all five patients in a case series of arthroscopic removal [95]. In four of five patients with silicone radial head prostheses, the radial head had already fractured [95]. Extensive synovitis was found in all cases of failed silicone radial head prostheses [95]. Histologic examination of the synovial tissues in failed silicone radial head prostheses showed a hystiocytic foreign body giant cell reaction [95]. Both surgical removal and revision to a new radial head prosthesis resulted in satisfying outcomes for silicone radial head prostheses [16].

Reoperation and Revision Outcomes: Almost 40% of patients (n 25) experienced complications during follow-up in a mid-term outcome study of acute trauma [97]. 20 patients (30.8%) required 1 additional surgical procedure during follow-up in a mid-term outcome study of acute trauma [97]. Most revision procedures were performed within 2 years after the index operation in a mid-term outcome study of acute trauma [97]. Removal of the radial head prosthesis was required in 4 patients, with 3 cases attributed to symptomatic loosening and 1 case attributed to breakage of the implant [97]. Patients who experienced complications and/or who underwent revision showed significantly lower outcome variables [97]. A second operation to revise or remove a radial head prosthesis occurred in 25% of 119 total prostheses in a study with a minimum follow-up of 8 years [179]. Seventy percent of re-operations for radial head prosthesis revision or removal occurred within a year, with a median time from initial to second surgery of 7 months [179]. Overall reoperation rates are high in patients undergoing operative treatment of radial head and neck fractures [210]. Infection and aseptic loosening were the major causes of reoperation in a study of primary total elbow arthroplasty [214].

Recovery

Rehabilitation protocol: Early range of motion is essential to prevent stiffness [180]. Immediate active mobilisation is safe and beneficial for Mason 1 and 2 radial head fractures [160]. Nondisplaced and minimally displaced radial head fractures can be treated non-operatively with early mobilization [80]. The use of stem auto-expansion as a mode of obtaining primary fixation in radial head arthroplasty appears to be an effective solution for reducing the risk of painful loosening [173].

Functional milestones: Patients report excellent Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups after radial head arthroplasty, despite any need for reoperation [25]. Midterm outcomes of EVOLVE radial head prosthesis are satisfactory, and associated complication rates are low [55]. Radial head implant polarity does not appear to affect functional outcomes [40].

Other Considerations: Although radial head arthroplasty for fractures has a high potential for reoperation within the first year, survival rates with uncemented implants remain high at 10 years [25]. Secondary osteoarthritis after resection of the radial head did not affect the functional outcome during the follow-up time in Mason-IV fracture dislocation [38]. Among active patients with radial head fractures treated with RHA, three-quarters will return to active duty military service, push-ups, and sport [167]. However, only about half of patients will return to their preinjury level of function [167], and half may report an adverse outcome unrelated to the prosthesis [167].

Key Evidence

• [L5] Clinical outcome studies of metallic radial head arthroplasty systems indicate that head replacement is a reasonable option to offer patients with comminuted radial head fractures and complex elbow trauma. [1] (10.1016/j.jhsa.2005.12.005)
• [L3] There were only submillimetre kinematic changes and small changes in joint pressure and interosseous membrane tension after the insertion of a radial head arthroplasty in an experimental setting. [2] (10.1002/jor.24488)
• [L4] The clinical and radiographic outcomes of revision surgery of radial head prostheses are favorable. [3] (10.1016/j.jse.2016.09.047)
• [Paper] Our experience and that of others with a similarly designed monoblock metallic radial head implant has encouraged the continued utilization of metallic radial head arthroplasty for unreconstructable radial head fractures at our center. [4] (10.1097/00130911-200112000-00003)
• [Paper] In most elbows, stability will be restored with placement of a radial head and repair of the lateral complex. [5] (10.1097/bte.0b013e318196c4d9)
• [L1] The reproducibility of results would be improved by using a minimum follow-up of three years combined with a consensus of the definition of the reasons for failure after radial head arthroplasty. [6] (10.1302/0301-620x.99b12.bjj-2017-0543.r2)
• [L4] Metal radial head implants are an attractive solution yielding good functional outcomes in recent limited series and personal experience, but a longer follow-up is necessary to judge their reliability. [7] (10.1016/j.main.2004.11.009)
• [L3] Longer-term studies will be required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening. [8] (10.1007/s11999-013-3331-x)
• [L4] Metallic radial head arthroplasty yields satisfactory results in acute unreconstructable radial head fractures or as a salvage procedure for previously treated radial head fractures. [9] (10.1016/j.jse.2005.09.010)
• [L3] Our study demonstrates significant radiographic differences between two frequently used radial head arthroplasty implants. [10] (10.1097/bot.0000000000000876)
• [L5] Radial head arthroplasty is a reliable procedure for complex radial head fractures not amenable to reconstruction, particularly when associated with unstable elbows or forearm injuries, provided concomitant injuries are addressed. [11] (10.1016/j.jhsa.2009.01.027)
• [L5] The medium term outcome of metallic radial head arthroplasty is encouraging; however, long-term follow-up studies are needed. [12] (10.1097/bte.0b013e3181d9ca6d)
• [L5] Medium-term data suggest that patients with comminuted radial head fractures do well with radial head replacement. [14] (10.1016/j.jhsa.2012.10.001)
• [L4] Younger patients should be counseled regarding the increased risk of requiring further surgery after radial head replacement. [15] (10.1007/s11999-014-3516-y)
• [L4] Both surgical removal and revision to a new radial head prosthesis resulted in satisfying outcomes. [16] (10.1016/j.jse.2021.10.043)
• [L4] The modular radial head arthroplasty used in this study showed promising findings in short to midterm results. [17] (10.5812/traumamon.20201)
• [L5] [18] (10.1016/j.jses.2017.06.001)
• [L4] The study shows a positive association between radiographic findings and patient symptoms for postoperative complications after radial head arthroplasty, validating radiography as the preferred postsurgical modality of imaging. [19] (10.2214/ajr.11.7674)
• [L4] The review aims to shed light into overlengthening as a complication of radial head replacement and to help identify and treat it. [20] (10.1007/s00402-020-03619-9)
• [L4] Although radial head resection could be a valid treatment in this group of patients, radial head arthroplasty would remain as the main option for the treatment of these lesions. [21] (10.1016/j.injury.2020.02.028)
• [L3] A secondary radial head prosthesis and a worse clinical outcome (MEPS < 85 points) significantly increase the risk of not returning to sports after radial head arthroplasty. [23] (10.1016/j.jse.2019.03.014)
• [L5] Restoration of the anatomic radial head height is critical when performing radial head arthroplasty to maintain normal joint biomechanics. [24] (10.1016/j.jhsa.2021.11.006)
• [L4] Although radial head arthroplasty for fractures has a high potential for reoperation within the first year, survival rates with uncemented implants remain high at 10 years, and patients report excellent Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups, despite any need for reoperation. [25] (10.1016/j.jhsa.2023.04.020)
• [L5] Adequate knowledge of the surgical indications, types of implants, and surgical technique are essential for a satisfactory outcome when a radial head prosthesis is used for the treatment of nonreconstructable radial head fractures. [26] (10.5435/jaaos-22-10-633)
• [L2] Given the available evidence, radial head replacement appeared to reach better outcomes in patients with Mason type III radial head fractures followed 5 years or less. [27] (10.1007/s00590-013-1367-y)
• [Paper] The decision to remove a radial head prosthesis may depend more on surgeon or hospital preferences than on objective problems with the prosthesis. [28] (10.1016/j.injury.2016.02.023)
• [L1] Implant fixation type does not appear to affect functional outcomes of radial head arthroplasty. [30] (10.1016/j.jse.2018.07.032)
• [L4] The radial head arthroplasty diameter can be predicted preoperatively in two-thirds of cases from a simple measurement of the humeral condyle diameter with an appropriate lateral view of a simple radiograph. [32] (10.1016/j.jse.2018.01.017)
• [L3] If impingement symptoms of radial head develop, secondary resection yields good results. [34] (10.1016/j.jse.2011.02.002)
• [L3] Anatomic radial head replacement has a risk of radiographic technical mistakes that correlate to poorer outcomes. [35] (10.1016/j.jseint.2026.101671)
• [L3] If a radial head prosthesis is used, prosthesis oversizing should be avoided as it may contribute to worse outcome with other radiographic abnormalities. [36] (10.1007/s00264-014-2478-8)
• [L4] Secondary osteoarthritis after resection of the radial head is a concern, but it did not affect the functional outcome during the follow-up time. [38] (10.1080/17453674.2017.1293440)
• [L2] Pyrocarbon radial head implants are a viable option for radial head arthroplasty. [39] (10.1016/j.otsr.2023.103750)
• [L1] Radial head implant polarity does not appear to affect functional outcomes. [40] (10.5397/cise.2023.01088)
• [L4] The anatomical parameters of the proximal radius of each case and the radial head implant specifications should be assessed when selecting a radial head implant. [41] (10.1007/s00264-015-2773-z)
• [L5] [42] (10.1302/0301-620x.95b2.29877)
• [L4] Clinically and radiographically, our results are similar to those reported in the literature, and suggest that in the short term, radial head prosthesis is a viable option for patients with instability after failed ORIF or radial head resection for radial head fractures. [44] (10.1080/17453670510045516)
• [L4] Better outcomes are reported for radial head arthroplasty in terms of elbow stability, range of motion, pain, and fewer complications compared to radial head excision. [45] (10.1155/2018/4020625)
• [L4] Due to the variety of implant designs and limited evidence, the current data provide no evidence for a specific radial head prosthesis design. [46] (10.1302/2058-5241.4.180099)
• [L4] Performing capitellar resurfacing arthroplasty at the time of metallic radial head arthroplasty should be considered when capitellar bone quality is poor. [47] (10.1016/j.jse.2007.04.009)
• [L4] Radial head arthroplasty with pyrocarbon radial head prosthesis is an acceptable option when treating unreconstructable radial head fractures yielding good functional and radiological outcomes. [48] (10.1111/ans.12908)
• [L5] It was not possible to consistently insert radial head prostheses anatomically. [49] (10.1016/j.jse.2007.12.008)
• [L3] [50] (10.1177/17585732241255952)
• [L4] The preferred treatment for failed radial head arthroplasty depends mainly on the chondral condition and stability of the elbow joint. [52] (10.1302/2058-5241.5.190055)
• [L4] Implant removal is a viable treatment strategy for failed radial head arthroplasty with good outcomes at average 7-year follow-up. [53] (10.1016/j.jse.2026.07.022)
• [L3] Long-term outcomes for radial head arthroplasty are satisfactory; however, there is a high complication and revision rate, resulting in implant survival of 75.1% at 18 years with the highest annual failure rate observed in the first postoperative year. [54] (10.1016/j.jse.2020.11.031)
• [L2] Midterm outcomes of EVOLVE radial head prosthesis are satisfactory, and associated complication rates are low. [55] (10.1177/1758573219850111)
• [L4] Risk of revision is directly correlated with implanted radial head diameter, and individuals who did not undergo a revision by 3 years tend to retain the implant. [57] (10.1016/j.jse.2022.09.024)
• [L3] Proximal radial neck resorption (PRNR) after press-fit radial head arthroplasty is a common radiological finding that develops in the first 24 months before stabilizing definitively. [66] (10.1302/0301-620x.105b8.bjj-2022-0817.r2)
• [L4] Bipolar and press-fit radial head arthroplasty gives unsatisfactory mid-term outcomes in the treatment of acute fractures of the radial head or their sequelae. [70] (10.1302/0301-620x.99b9.bjj-2016-1043.r2)
• [L5] The intraoperative decision to fix or replace the radial head is critical to optimize treatment outcomes. [71] (10.1016/j.hcl.2004.06.003)
• [L3] Radial head resection is preferable if the elbow is stable due to being less demanding and cheaper, while replacement is recommended for unstable elbows. [74] (10.1007/s00264-014-2594-5)
• [L5] However, none of the prostheses functioned as well as the native radial head, suggesting that open reduction and internal fixation to restore radial head anatomy is preferable to replacement when possible. [75] (10.2106/00004623-200112000-00010)
• [L4] The incidence of neurologic complications associated with the surgical treatment of complex elbow fractures requiring implantation of a radial head prosthesis may be underestimated in the literature. [76] (10.1016/j.jse.2020.01.086)
• [L5] Nondisplaced and minimally displaced radial head fractures can be treated non-operatively with early mobilization. [80] (10.1530/eor-24-0035)
• [L1] Recommendations for surgical treatment of radial head and neck fractures according to the Mason classification can now be given with the best available evidence. [84] (10.1016/j.injury.2013.04.003)
• [L4] At the time of short-term followup, arthroplasty with a metal radial head implant was found to have been a safe and effective treatment option for patients with an unreconstructible radial head fracture; however, long-term follow-up is still needed. [85] (10.2106/00004623-200108000-00010)
• [L5] Prosthetic radial head height appears 2.2 ± 0.4 mm more proximal than the coronoid lateral edge on anteroposterior fluoroscopy when the articular surface is even with the coronoid. [87] (10.1016/j.jse.2016.04.014)
• [Paper] The kinematics of the elbow joint deviated increasingly from the native joint kinematics with a +2 mm to a +4 mm radial overlengthening. [89] (10.1016/j.jseint.2024.08.030)
• [L5] [90] (10.1016/j.medengphy.2004.04.011)
• [L5] The kinematics of the elbow deviated increasingly from those of the native joint with a 2 mm to a 4 mm lengthening of the radius. [91] (10.1302/0301-620x.106b10.bjj-2024-0405.r1)
• [L5] The results suggest that fractures of the radial head cannot be treated by simple excision without altering the basic kinematics of the elbow joint. [92] (10.1016/s1058-2746(99)90135-0)
• [Paper] However, a few degrees or mm changes in elbow kinematics could potentially increase stress to the interosseous membrane and contact pressure within the joint, and evaluation of these parameters are encouraged. [93] (10.1016/j.jseint.2024.08.031)
• [L4] [95] (10.1007/s00167-009-0796-y)
• [L4] [97] (10.1016/j.jse.2023.05.012)
• [L4] Our findings reveal that the commercially available metallic radial head design may overestimate the dimensions of the radial neck, and inadequate sizing may lead to an inadvertent change in proximal radial length with potentially adverse effects on elbow, forearm, and wrist mechanics. [99] (10.1016/s1058-2746(99)90079-4)
• [L5] Proper balancing and adequate bone resection from radial head is mandatory for obtaining normal elbow kinematics during the radial head arthroplasty procedure. [101] (10.1007/s00402-006-0164-z)
• [L4] Surgical implantation of personalized radial head prosthesis is a treatment modality with easy application, short operating time, and good functional results. [104] (10.1016/j.jse.2022.10.010)
• [L5] However, the kinematics of the radiocapitellar joint are different after bipolar arthroplasty than in the normal elbow, with abnormal positioning of the prosthetic radial head in supination and evidence of insufficient intraprosthetic motion. [109] (10.1016/j.jse.2009.09.015)
• [L5] The ligaments have the most marked influence on stability, particularly when the upper limb is positioned such that valgus and varus gravity loads are applied to the elbow. [113] (10.1016/j.jse.2004.09.034)
• [Case_report] Due to the potential for component dissociation, a bipolar radial head prosthesis may be relatively contraindicated in patients with, or at risk for, persistent elbow instability. [126] (10.1016/j.jse.2008.02.020)
• [L5] The authors state that for fractures with three or more articular fragments or those not amenable to stable internal fixation, they prefer excision of the radial head and prosthetic replacement using monopolar, metallic radial head implants with modular components and a smooth neck. [129] (10.1016/j.jhsa.2014.10.029)
• [L5] Treatment of the Essex–Lopresti lesion with a radial head replacement alone prevents proximal migration, but does not restore normal forearm biomechanics. [131] (10.1016/j.jhsb.2005.10.009)
• [L5] This study found no statistical differences in radiocapitellar joint contact mechanics as measured by 3-dimensional joint congruency among the three implant geometries in cadaveric specimens undergoing continuous simulated forearm rotation. [132] (10.1016/j.jhsa.2017.03.009)
• [L5] The radial head prosthesis mimics the mechanics of the native radial head in terms of mean contact area, mean contact pressure, and peak contact pressure; however, different patterns of contact pressure and area curves during elbow flexion-extension were observed. [133] (10.1016/j.jhsa.2018.08.005)
• [L4] Neither radiographic landmark is sufficiently reliable to adequately assess radial head prosthetic overlengthening. [135] (10.1016/j.jse.2026.06.024)
• [L4] [142] (10.1016/j.jse.2021.05.017)
• [L4] A single component would suffice for right and left elbows, but a perfectly conforming prosthesis is practically impossible due to large variations in normal anatomy. [146] (10.1016/j.jse.2004.10.012)
• [L4] A nonparallel medial ulnohumeral joint space may suggest overstuffing, but comparing radiographs of the uninjured elbow is the best investigation when overstuffing is suspected. [149] (10.1016/j.jhsa.2007.02.024)
• [L4] The overall midterm outcome of this series of 30 press-fit bipolar radial head arthroplasties can be considered favorable. [150] (10.1016/j.jse.2016.02.007)
• [L5] The measured landmarks show no consistent rotational relationship with the maximum diameter of the radial head. [156] (10.1016/j.jse.2013.02.013)
• [L1] This study demonstrated the safety and early benefit of immediate active mobilisation in Mason 1 and 2 radial head fractures. [160] (10.1016/s0020-1383(02)00164-x)
• [L4] However, patients with RHA implanted within 4 weeks for nonreconstructable fractures of the radial head sustained a limited number of failures and, despite a relatively high rate of post-traumatic arthritis, obtained a good long-term clinical outcome. [165] (10.1016/j.jse.2025.06.026)
• [L4] Among active patients with radial head fractures treated with RHA, three-quarters will return to active duty military service, push-ups, and sport; however, half may report an adverse outcome unrelated to the prosthesis and only about half of patients will return to their preinjury level of function. [167] (10.1016/j.jhsa.2017.04.005)
• [L3] Concomitant elbow fractures or dislocations do not affect the longer term outcomes of patients with unreconstructable radial head fractures requiring radial head arthroplasty. [169] (10.1016/j.jse.2017.06.031)
• [L5] [170] (10.1177/1758573219876921)
• [L5] Despite significant advances in understanding complex elbow instability and implant design, RHA has not yet become the gold standard for treatment of non-reconstructible radial head fractures. [171] (10.1007/s00264-018-4082-9)
• [L1] The use of stem auto-expansion as a mode of obtaining primary fixation in radial head arthroplasty appears to be an effective solution for reducing the risk of painful loosening. [173] (10.1007/s00264-018-4070-0)
• [L5] Intraoperative visualization of a gap in the lateral ulnohumeral joint is a reliable indicator of overlengthening following the insertion of a radial head prosthesis. [174] (10.2106/jbjs.j.00356)
• [L5] [179] (10.1097/corr.0000000000000913)
• [L5] Early range of motion is essential to prevent stiffness, and severely comminuted fractures not amenable to fixation should be managed with radial head replacement. [180] (10.1016/j.hcl.2007.01.009)
• [Paper] This 3D evaluation technique seems to provide an accurate and precise method for assessing prosthesis placement in radial head arthroplasty with minimal measurement errors. [181] (10.1016/j.jseint.2024.08.057)
• [L4] [186] (10.1016/j.otsr.2015.06.026)
• [L5] Radial head diameter measurements showed excellent reliability, suggesting that the excised radial head, when available, should be used to select the implant diameter. [188] (10.1016/j.jse.2013.04.005)
• [L5] The radiographic measurement method of Athwal et al. can be used to estimate and diagnose the magnitude of overlengthening of the MoPyC radial head prosthesis, although sensitivity is limited (76%) for small overlengthening of 1.5 mm. [192] (10.1007/s00402-019-03187-7)
• [L5] [194] (10.1177/17585732261487599)
• [L4] [199] (10.1016/j.jse.2011.01.032)
• [L4] [200] (10.1016/j.jse.2003.11.007)
• [L4] The study demonstrates an excellent survival of press-fit radial head arthroplasty of 92.1% at 10 years. [204] (10.1177/17585732241268904)
• [L4] Our systematic review established that RHA results in satisfactory clinical outcomes and modest complication and revision rates at long-term follow-up, despite high levels of radiologic degenerative changes over the same period. [208] (10.1016/j.jse.2021.03.142)
• [L3] Overall reoperation rates are high in patients undergoing operative treatment of radial head and neck fractures. [210] (10.1177/1558944719837691)
• [L4] Infection and aseptic loosening were the major causes of reoperation. [214] (10.1016/j.jse.2026.08.030)

See Also

• Radial Head Fracture
• Ligament Injuries
• Elbow Instability
• Elbow Arthroplasty

References

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