Replacement arthroplasty of the radial head is indicated when fracture, deformity and/or arthrosis of the radiocapitellar joint is accompanied by posterolateral or axial instability. Collateral ligament instability derived from trauma or longstanding attenuation in conjunction with loss of axial support results in instability of the elbow and dysfunction. In the face of trauma restoration of columnar support at the radiocapitellar joint relies on the ability to reconstruct the radial head and neck. When this is impossible or following a failed attempt to do so, the result is pain, dysfunction and loss of control. With loss of the interosseous ligament, integrity longitudinal instability results in dysfunction more distally at the wrist as well as instability at the elbow. Silastic prosthetic replacement has been shown to be inadequate while soft tissue reconstruction alone is both difficult and unpredictable. Restoration of columnar support through replacement of the radial head has been effective in restoring stability but has relied upon standard sized prostheses, which do not always conform with anatomy. The authors have developed a radial head prosthetic system which closely approximates the native anatomy in terms of intramedullary fit, reestablishment of radial head height, and diameter accommodation to be able to adequately close soft tissue capsular and ligamentous structures without “overstuffing” the proximal radioulnar joint. The modular implant utilizes the concept of a central axis of forearm pronation and supination establishing a neck cut perpendicular to this long axis rather than perpendicular to the anatomic neck. This allows the replaced head to sit opposed to the capitellum at all times during pronation and supination. The radial head itself is sized to restore appropriate length longitudinally but is downsized at least 2 mm to allow adequate soft tissue closure, preventing overstuffing. A variety of sizes of stem and head length and width are provided in the “emergency trauma tray” with spacer rings of 1 mm and 2 mm to provide up to the 3 mm additional length as needed. For reconstruction cases, custom implants are measured and designed through markers placed on standardized x-rays and are constructed within five working days to provide an anatomic replacement exactly fitting the patient’s anatomy. The prosthetic head is easily removed from the stem for trial and sizing purposes. Each implant comes with its own set of instruments for exposure, broaches and inserters. Twenty-three patients with both acute and chronic pathology at the proximal radio-ulna and radiocapitellar joints with instability have been managed with this anatomic modular system. No patients have required revision. All have remained stable and pain relief has been significant with a decrease on a pain visual analog scale from an average of 8.5 to 1.2 and an increase in the arc of pronation and supination from 50° to 160°. There have been no infections. One patient has shown some lucency about the radial stem but clinically has had no symptoms of pain, instability or loosening. This system which attempts to recreate functional anatomy has proven to be effective in restoring stability while simplifying the surgical technique through use of user-friendly implants and surgical instrumentation. If noted, the author indicates something of value received. The codes are identified as follows: a, research or institutional support; b, miscellaneous funding; c, royalties; d, stock options; e, consultant or employee. *The Food and Drug Administration has not cleared the drug and/or medical device for the use described in this presentation (ie, the drug or medical device is being discussed for an “off-label” use). If noted, the author indicates something of value received. The codes are identified as follows: a, research or institutional support; b, miscellaneous funding; c, royalties; d, stock options; e, consultant or employee. *The Food and Drug Administration has not cleared the drug and/or medical device for the use described in this presentation (ie, the drug or medical device is being discussed for an “off-label” use).