Headless screws for radial head fractures may yield decreased complications vs. miniplates
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Key takeaways:
- Headless screws yielded significantly fewer complications vs. miniplates for radial head fractures.
- However, researchers noted the differences between screw vs. plate fixation may not be clinically relevant.
According to results from a randomized controlled trial of patients with radial head fractures, headless screws yielded better range of motion with fewer complications compared with miniplates, despite similar union rates.
Ahmed Afifi, MD, PhD, from the department of orthopedic surgery at Cairo University in Egypt, and colleagues performed a single-center, prospective, randomized controlled trial of 60 patients who underwent surgery for an isolated radial head fracture between 2020 and 2023.
Afifi and colleagues randomly assigned 30 patients (mean age, 32.8 years) to receive fixation with headless compression screws and 30 patients (mean age, 35.5 years) to receive fixation with miniplates.
Afifi and colleagues evaluated outcomes at a final follow-up of 18 months. Outcomes included union rates on radiographs using the Mayo Elbow Performance Score (MEPS), range of motion, VAS pain scores, grip strength and DASH scores.
Researchers found all patients had successful unions at a mean 8 weeks for the screw group and a mean 8.5 weeks for the plate group. Patients in the screw group returned to daily activities at a mean 10.4 weeks, while patients in the plate group returned to daily activities at a mean 11.8 weeks.
Flexion, VAS pain scores, grip strength and DASH scores were similar between the groups at final follow-up. However, Afifi and colleagues found MEPS was significantly better in the screw group (87.7) compared with the plate group (80.5). Researchers also noted patients in the screw group had improved supination and pronation, as well as a decreased overall complication rate (3.3% vs. 26.7%), compared with patients in the plate group.
“These advantages of screw fixation could allow easier rehabilitation with earlier return to activities as proved by this study,” Afifi and colleagues wrote in the study.
“While the MEPS was statistically better in the screw group, the difference was below the [minimal clinically important difference] MCID for the MEPS, and as such it is not certain that the two treatments are different clinically,” they concluded.
Perspective
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I commend the authors on their completion of a high-quality, prospective, randomized, clinical trial on a relevant clinical topic. They found that headless screw fixation of displaced radial head fractures was superior to plate fixation in a number of areas. This included a 7-point improvement in the Mayo Elbow Performance Score (the clinical significance of which could be debated), a 23° improvement in forearm rotation and a significantly decreased complication rate (3.3% in the screw group vs. 27% in the plate group). Interestingly, in this study, the authors were able to fix even three- and four-part fractures with the headless screw technique, which many orthopedic surgeons find quite challenging.
In addition, having no patients lost to follow-up in a 60-patient fracture study is truly remarkable. I particularly appreciate figure 1, which shows that of 93 patients eligible for the study, 60 were included. This is an important point for the reader to realize that the study group includes most of the patients that presented with radial head fractures and not a select group amenable to fixation (as opposed to arthroplasty).
This study does support the general surgical trend away from plate fixation for these fractures toward headless screw fixation, where possible. This certainly parallels my experience of a high rate of rotational stiffness and subsequent hardware removal following plate fixation in this setting.
One question unanswered by this study is what the exact role of radial head arthroplasty is, particularly since the participating surgeons seem to have had success fixing three- and even four-part radial head fractures. Overall, I do think that a dramatically reduced complication rate and improved forearm rotation support the use of the headless screw technique where feasible.
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