Implant selection and fixation in radial head arthroplasty: A qualitative analysis of surgeon decision-making.

Background: Radial head arthroplasty (RHA) requires surgeons to choose an implant and a fixation strategy where comparative trial evidence is sparse. How training, intraoperative judgement and tactile feedback shape these choices remains poorly characterised. Methods: Ten UK consultant orthopaedic surgeons sub-specialised in upper-limb arthroplasty and elbow surgery were recruited through purposive and snowball sampling and interviewed using a semi-structured guide. Transcripts underwent inductive thematic analysis until no new conceptual categories emerged. Results: Five themes and 13 sub-themes were identified: implant selection drivers; fixation philosophy; intraoperative cues; patient profiles and outcomes. Surgeons applied pragmatic, reproducible heuristics where comparative trial evidence is absent. Convergence centred on bone quality as the pivotal determinant of fixation, on modularity for managing anatomical variability and on functional rather than radiographic definitions of success. Surgeons diverged on the threshold for the 'unfixable' fracture, on primary stem fixation philosophy and on whether excision remains an acceptable definitive option in low-demand elderly patients. Discussion: Surgeons apply systematic, shared heuristics under uncertainty. Several prioritised determinants, including tolerance of controlled stem toggle, intraoperative bone quality assessment and avoidance of overstuffing, are not captured by current quantitative frameworks. These findings are hypothesis-generating and identify candidates for future comparative work.