Risk of Subluxation or Dislocation After Operative Treatment of Terrible Triad Injuries

The anconeus-triceps lateral flap approach in terrible triad of the elbow: good outcome in a series of ten cases

Introduction

Standard surgical management for the terrible triad of the elbow (TTE) has been established since 2004, yet postoperative complications are common and consensus on optimal management is absent. Different surgical algorithms for treating TTE and their efficacy have been reported worldwide, yet evidence from Vietnam remains limited.

Methods

Ten cases diagnosed with TTE admitted to the Hospital of Traumatology and Orthopedics, a tertiary orthopedic center in Ho Chi Minh City, were presented to demonstrate the effectiveness and rate of postoperative complications following our stepwise surgical procedures using the anconeus-triceps lateral flap approach. The intraoperative "drop sign", quantitative assessment of pain and level of upper arm disability (via VAS and QuickDASH score) was mentioned to assess the algorithm's benefit. All patients' information was retrieved from medical records from August 2022 to January 2024.

Results

All 10 cases required repair of the lateral ligament complex and underwent surgery within 2 days of hospitalization. Immediate postoperative imaging revealed no drop sign, and none of the patients experienced elbow dislocation nor the need for repeated surgery, and a full range of elbow motion was demonstrated at 3-6 months follow-up.

Conclusion

TTE is a challenging injury that almost always obligates surgical correction. The anconeus-triceps lateral flap approach, with its advantages of better visualization and preservation of certain essential stabilizing muscles of the elbow, was demonstrated to yield a high success rate and low postoperative complication rate.

Using External Joint Stabilizer - Elbow (EJS-E) for treating elbow instability-biomechanical assessment and clinical outcomes

BACKGROUND

This study aimed to evaluate the outcome of using an External Joint Stabilizer - Elbow (EJS-E) for persistent elbow instability based on biomechanical experiments and analysis of clinical results.

METHODS

An EJS-E was used in 17 elbow instability patients. The median follow-up was 26 months (range, 12-42 months). We evaluated the flexion-extension and pronation-supination movement arcs, visual analog scale (VAS) score, Mayo Elbow Performance Score (MEPS), Broberg and Morrey classification system, and occurrence of complications in these patients. Moreover, construct stiffness and maximum strength tests were performed to evaluate the strength of the fixation techniques.

RESULTS

The final median range of the extension-to-flexion and pronation-to-supination arc of the elbow was 135° (range, 110°-150°) and 165° (range, 125°-180°), respectively. The VAS pain scores were > 3 in two patients. The median MEPS was 90 (range, 80-100 points). Five patients showed signs of grade I post-traumatic osteoarthritis according to the Broberg and Morrey radiographic classification system, while grade II changes were observed in three patients. Complications included axis pin loosening with pin-tract infection in two patients, transient ulnar nerve symptoms in two patients, heterotopic ossification in two patients, and suture anchors infection in one patient. Based on the biomechanical testing results, the EJS-E exhibited higher stiffness and resisting force in varus loading. It was 0.5 (N/mm) stiffer and 1.8 (N·m) stronger than the internal joint stabilizer (IJS) by difference of medians (p < 0.05).

CONCLUSIONS

Biomechanical and clinical outcomes show that EJS-E via the posterior approach can restore mobility and stability in all patients, thus serving as a valuable alternative option for the treatment of persistent instability of the elbow.

Unique indications for internal joint stabilizer for elbow instability

BACKGROUND

Treatment of elbow instability remains challenging despite advancements in surgical techniques. The objective of this study was to evaluate obesity, advanced age or frailty, and altered cognitive function (because of mental handicap, stroke, dementia, or traumatic brain injury) as unique indications for the use of the internal joint stabilizer (IJS) to augment surgical treatment of elbow instability.

METHODS

This was a retrospective review of all patients 18 years and older with elbow instability who were managed with an IJS along with standard measures of care for their specific injury, such as fracture fixation and collateral ligament reconstruction. Patients were excluded if they did not have a minimum follow-up of 3 months. All patients were treated by a single shoulder and elbow fellowship-trained orthopedic traumatologist at an urban university-based level 1 trauma center.

RESULTS

Twenty-two patients were included in the study. Five patients were 60 years of age or older. Nine patients had a body mass index of 30 or greater. Five patients had a history of 1 or more cerebral insults or cognitive impairment. The majority of patients (21/22; 95%) regained elbow stability after the index surgery. At last follow-up, 14 of 22 patients (63%) regained a functional arc of motion, defined as at least 100° arc of motion, and 77% of patients had at least 90° of motion. Complications requiring revision surgery included culture-negative recurrent elbow instability (n = 1), deep infection (n = 1), and IJS failure without recurrent instability (n = 1). The IJS was removed in all 3 cases. Twelve patients underwent delayed IJS removal >2 months after the index surgery to grant additional time for bony and ligamentous healing and to permit secondary contracture release at the time of IJS removal. No complications were seen from delayed IJS removal.

CONCLUSION

The IJS may be used to create elbow stability in complex patients, regardless of weight, frailty, cognitive function, neurologic insult, or other comorbidities. Unlike external fixation, the IJS does not require pin site care and is relatively light and low-profile. When augmenting surgical fixation for elbow instability, the IJS may be preferable for patients with complex comorbidities or social dynamics.

Posterior (Boyd) approach to terrible triad injuries

Background

A ‘terrible triad injury of the elbow’ (TTIE) refers to an injury pattern involving posterior dislocation of the ulnohumeral joint, fracture of the radial head, and fracture of the coronoid process of the ulna. It is a complex injury to the elbow joint and can result in long-term elbow instability, pain, stiffness, and arthritis. In specific cases, it may be treated conservatively, but in most circumstances, surgical stabilization is advised.

The ‘drop sign’ is an objective static radiographically measured ulnohumeral distance of ≥4 mm seen intraoperatively and postoperatively. Although controversial, it may portend postoperative instability and arthritis. The senior author repairs these injuries in a standardized fashion through a modified Boyd rather than a lateral approach. Our aim was to assess the number of cases demonstrating an intraoperative drop sign after surgical treatment of a TTIE with this approach.

Methods

We retrospectively analyzed 22 consecutive patients with 23 acute TTIEs. These injuries were treated by a single surgeon using a modified Boyd (posterior) approach to the elbow. Intraoperative image intensifier x-rays were analyzed by the two authors to assess for a ‘drop sign’.

Results

None of the 23 cases had ‘drop signs’ on intraoperative imaging after stabilization. No patient has redislocated, underwent reoperation, or had symptoms of instability at follow-up.

Conclusion

None of our patient cohort had an intraoperative ‘drop sign’ after standardized stabilization for a TTIE injury using a modified Boyd approach.

Analysis of Fracture Characteristic and Medial Collateral Ligament Injury Relationships in Terrible Triad Elbow Injuries

PURPOSE

The objectives of this study were to identify the relationship between fracture characteristics and medial collateral ligament (MCL) injuries in terrible triad injuries of the elbow.

METHODS

Between 2010 and 2018, 60 patients who underwent surgery for terrible triad elbow injuries were retrospectively reviewed. Using magnetic resonance imaging (MRI) assessments, patients were stratified into those who had intact or low-grade partial MCL tears (low-grade MRI-MCL group) and those who had high-grade partial or full-thickness MCL tears (high-grade MRI-MCL group). We also analyzed patients according to whether they underwent MCL repair surgery. Fractures of the radial head were assessed according to Mason's classification system and measurements of fracture fragment arc on axial cuts. Fractures of the coronoid processes were assessed according to the system of Regan and Morrey and measurements of coronoid process volumes.

RESULTS

Patients in the high-grade MRI-MCL group (28 patients) had a more comminuted and higher fragment arc of radial head fractures than those in the low-grade MRI-MCL group (32 patients) (143º ± 45º vs 119º ± 31º). However, the volume of coronoid fracture fragments was smaller in the high-grade MRI-MCL than in the low-grade MRI-MCL group (359 ± 325 mm³ vs 722 ± 448 mm³). The MCL repair group (22 patients) also had a more comminuted and higher fragment arc in radial head fractures (153º ± 44º vs 117º ± 31º) and a smaller coronoid process fracture volume (236 ± 224 mm³ vs 735 ± 419 mm³) than the non-MCL repair group (38 patients).

CONCLUSIONS

Our results demonstrated that high-grade MCL injuries are associated with comminuted and larger-sized radial head fractures, as well as smaller-sized coronoid process fractures in terrible triad injuries. In making a decision regarding surgical treatment, these fracture characteristics could help to predict the severity for MCL injury in terrible triad injuries.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

What Factors Are Associated with Reoperation After Operative Treatment of Terrible Triad Injuries?

BACKGROUND

Terrible triad injuries of the elbow, consisting of posterior ulnohumeral joint dislocation with associated fractures of the radial head and coronoid process, are challenging injuries due to the difficulty in restoring stability to the joint surgically while also attempting to allow early ROM to prevent stiffness. Furthermore, complications are both debilitating and relatively common, frequently requiring reoperation.

QUESTIONS/PURPOSES

(1) What patient-, injury-, or surgery-related factors are associated with reoperation after surgical treatment of terrible triad injuries of the elbow? (2) What are the most common causes of reoperation after these injuries?

METHODS

Between January 2000 and June 2017, we identified 114 patients who had surgery for terrible triad injuries at two tertiary-care referral centers. Of those, 40% (46 of 114) were lost to follow-up before 1 year, and an additional 5% (6 of 114) were excluded because they underwent the index surgery at an outside institution (n = 4) or underwent closed reduction with or without percutaneous pinning (n = 2). That left 62 patients for analysis in this retrospective study with a minimum of 1-year follow-up (median 22 months; range 12 to 65) or who met the endpoint of reoperation before 1 year. During the study period, indications for surgical treatment of terrible triad injuries of the elbow included joint incongruity or instability precluding early ROM. In our study cohort, 45% (28 of 62) underwent reoperation. Indications for reoperation after surgical treatment included stiffness that interfered with activities of daily life, symptomatic prominent hardware, ulnar neuropathy, instability of the elbow joint at rest or with range of motion, and infection. Patient-related (such as age, sex, race), injury-related (for example, ipsilateral extremity fracture, open fracture), and surgery-related factors (for instance, time to surgery, radial head treatment) as well as outcomes were collected by the treating surgeon at the time of follow-up and ascertained using chart review. The primary outcome measure was reoperation after surgical treatment of a terrible triad injury of the elbow. Bivariate analysis was used to assess whether explanatory variables were associated with reoperation after surgical treatment of terrible triad injuries of the elbow.

RESULTS

Of the patient-, injury-, and surgery-related factors that were analyzed, only radial head treatment was associated with an increased reoperation risk (p = 0.03). No other variable met criteria for inclusion in our multivariable logistic regression model (p < 0.10), and therefore, a multivariable logistic regression model was not performed. The most common indication for reoperation was stiffness (21% [13 of 62 patients]), followed by symptomatic hardware (18% [11 of 62 patients]), nerve symptoms (ulnar neuropathy 16% [10 of 62 patients] and incisional neuroma 2% [1 of 62 patients]), instability (6% [4 of 62 patients]), and wound problems (infection 2% [1 of 62 patients]).

CONCLUSION

The reoperation risk after surgical treatment of terrible triad injuries of the elbow is high. No patient- or injury-related factors were associated with the reoperation risk. Based on our finding, we recommend fixation of radial head fractures in these injuries when feasible and compatible with early postoperative motion, and we suggest the use of radial head excision or arthroplasty as a secondary options.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Elbow Fracture-Dislocations: Determining Treatment Strategies

Elbow dislocations represent common injuries. A quarter of these injuries involve at least 1 fracture. The sequel of elbow fracture-dislocations can be fraught with complications, including recurrent instability, posttraumatic arthritis, elbow contracture, and poor functional results. The 3 main patterns of injury are valgus posterolateral rotatory instability, varus posteromedial rotatory instability, and transolecranon fracture-dislocation. This article discusses each pattern individually, including the anatomy, the typical injury pattern, and treatment strategies. It also discusses common complications that can occur.

Prediction and Potential Preventions for the Development of Posttraumatic Osteoarthritis after the Terrible Triad Injury: A Multicenter Risk Factors Study

Objective

A multicenter study to evaluate risk factors for the development of moderate or severe posttraumatic osteoarthritis (PTOA) and to find potential preventions.

Methods

We conducted a retrospective multicenter study including the terrible triad injury (TTI) patients with surgical treatment from January 2007 to November 2014. Demographics, injury information, and treatment history were obtained retrospectively. According to the Broberg and Morrey criterion, 198 included patients were sorted into two groups: the mild or no PTOA and moderate or severe PTOA. Uni- and multivariate logistic regression analyses were used to identify risk factors for moderate or severe PTOA.

Results

Moderate or severe PTOA was present in 64 patients (32.3%). Significant risk factors were Mason III radial head fracture (OR 4.049, 95% CI 1.877-8.736, p < 0.001), medial collateral ligament injury (OR 5.120, 95% CI 1.261-20.790, p = 0.022), and heavy use of elbow (OR 2.333, 95% CI 1.060-5.136, p = 0.035). Besides, patients suffered subluxation (p = 0.007) and those with more risk factors had a higher risk to develop moderate or severe PTOA.

Conclusions

Moderate or severe PTOA was common after the TTI. Patients need to be counseled about avoiding heavy use of the elbow, especially for those with Mason III radial head fractures. Surgeons should be aware of the recurrent instability of the elbow.

Patient outcomes for the Internal Joint Stabilizer of the Elbow (IJS-E)

BACKGROUND

Recently, the Internal Joint Stabilizer of the Elbow (IJS-E) was developed as an internal dynamic fixator for use in the setting of traumatic elbow instability. This study reviews the patients who had an IJS-E placed at our institution. Specifically, postoperative complications, postoperative functional outcomes, and need for subsequent procedures were reviewed.

METHODS

A retrospective chart review was conducted of patients in whom the IJS-E was implanted from June 2016 to July 2018. Indications for use, range of motion at final follow-up, and the need for subsequent procedures were reviewed. Disabilities of the Arm, Shoulder, and Hand (DASH) and Broberg-Morrey scores were also obtained.

RESULTS

Ten IJS-E devices were implanted into 10 patients. Average length of follow-up was 13.4 months. Average flexion-extension and pronation-supination motion arcs at final follow-up were 106° and 141°, respectively. Seventy-eight percent of patients achieved >100° arcs of both flexion-extension and pronation-supination. Average DASH and Broberg-Morrey scores were 28.7 and 68.2, respectively. Four subsequent procedures were required in 4 patients: 2 contracture releases, 1 medial collateral ligament reconstruction, and 1 total elbow arthroplasty. There were no postoperative infections or nerve injuries.

DISCUSSION

The IJS-E has replaced the use of external hinged fixation at our institution. Final range of motion was consistent with that reported for terrible triad and complex elbow dislocation injuries. The IJS-E is a good option for use in patients with traumatic elbow instability, as it restores motion and function without immediate postoperative complication. However, it does not eliminate the potential for future operative intervention in these complex injuries.

Post-traumatic elbow stiffness: Pathogenesis and current treatments

Post-traumatic elbow stiffness is a major cause of functional impairment after elbow trauma. A stiff elbow limits patients' ability to position their hand in space for optimal use of their upper extremities, and as such, is a frequent indication for reoperation. This article reviews current concepts on the pathogenesis of post-traumatic elbow stiffness. Current nonoperative treatment options include therapy, bracing, and manipulation under anesthesia, while operative treatment options include arthroscopic and open arthrolysis. The pros and cons of various treatment options are discussed, with a focus on the evidence supporting their use, the expected functional gains, and associated complications. Future directions in post-traumatic elbow stiffness are highlighted.

Minimizing Posttraumatic Osteoarthritis After High-Energy Intra-Articular Fracture

This article serves to provide an overview of molecular and surgical interventions to minimize the progression of posttraumatic arthritis following high-energy intra-articular fractures. The roles of cartilage and the microcellular environment are discussed, as well as the response of the joint and cartilage to injury. Molecular therapies, such as glucocorticoids, mesenchymal stem cells, and bisphosphonates, are presented as potential treatments to prevent progression to posttraumatic arthritis. High-energy intra-articular fractures of the elbow, hip, knee, and ankle are discussed, with emphasis on restoring anatomic alignment, articular reduction, and stability of the joint.

Risk Factors That Influence Subsequent Recurrent Instability in Terrible Triad Injury of the Elbow

OBJECTIVE

To identify risk factors associated with subsequent recurrent instability and to identify predictors of poor outcomes in terrible triad injury of the elbow.

DESIGN

Retrospective cohort study.

SETTING

University trauma center.

PATIENTS/PARTICIPANTS

Seventy-six patients who were surgically treated for terrible triad injury of the elbow.

INTERVENTION

Review of charts and standardized x-ray images before surgery and 2 years after surgery. Patients were categorized into 2 groups: recurrent instability (group A) or concentric stability (group B).

MAIN OUTCOME MEASUREMENT

Primary outcome measures were injury mechanism, time between injury and operation, fracture type, ligament injury, radial head fixation, coronoid fixation, ligament repair, period of postoperative immobilization, joint space restoration, healing progress, secondary operation, functional outcomes, and complications. Secondary outcome measures were age, sex, height, body mass index, bone mineral density, and comorbidities (hypertension and diabetes). Outcomes were measured before surgery and 2 years after surgery and were compared between groups.

RESULTS

Recurrent instability occurred in 19.7% of cases; revision surgeries were performed in 12 cases (80%). High-energy trauma (P = 0.012), time between injury and operation (P = 0.001), radial head comminution (P = 0.001), medial collateral injury (P = 0.041), and coronoid nonrepair (P = 0.030) were associated with recurrent instability. Posttraumatic arthritis developed more often in group A (P = 0.001).

CONCLUSIONS

Recurrent instability was associated with high-energy trauma, time between injury and operation, Mason type III radial head fracture, medial collateral injury, and coronoid nonrepair. Patients with recurrent instability were more likely to require secondary surgery and develop posttraumatic arthritis than those with concentric stability.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors of efficacy for patients receiving surgical treatment following terrible triad of the elbow joint: A comparative study

BACKGROUND

This study aims to explore the efficacy of surgical and conservative treatment for elbow joint terrible triad, and evaluate related factors affecting surgical treatment efficacy.

METHODS

Patients with terrible triad of elbow joint (n = 165) were selected, among which 79 cases underwent conservative treatment (the control group) and 86 cases underwent surgical treatment (the experimental group). The range of flexion and extension, range of rotation and Mayo elbow performance score were recorded. In the experimental group, postoperation, according to the Mayo elbow performance score, patients were assigned into the effective group (72 cases) and ineffective group (14 cases). All patients were followed up regularly for 6 to 24 months. X-ray and computed tomography examination were used to examine anterior and posterior elbow joints preoperatively and postoperatively and the degree of arm rotation.

RESULTS

The range of flexion and extension, range of rotation and Mayo elbow performance score were found to be significantly higher in the experimental group after treatment compared to the experimental group before treatment and in the control group after treatment. Seven days after treatment, compared with the control group, the expressions of interleukin (IL)-6, C-reactive protein, IL-8, and tumor necrosis factor-α in serum decreased, and returned to almost near normal levels in the experimental group. Age, mean operative time, and postoperative immobilization time were significantly different between the effective and ineffective groups. The incidence of joint stiffness, heterotopic ossification, and ulnar nerve symptoms in the effective group were lower than those in the ineffective group. The postoperative immobilization time served a protective factor for the efficacy of surgical treatment of elbow joint terrible triad, while age served as a risk factor.

CONCLUSION

The results indicated that surgical treatment regimens for elbow joint terrible triad exhibited better efficacy than conservative treatment regimens, and lower age and longer postoperative immobilization time serve as protective factors for surgical treatment efficacy.

Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach

Objective

To report the results of the surgical treatment of terrible triad injury with anteromedial coronoid fracture through a combined surgical approach.

Methods

This retrospective study evaluated data from patients who underwent surgery to repair terrible triad injuries and anteromedial coronoid fractures. Surgical treatment involved radial head repair or replacement, medial and lateral collateral ligament repair, and coronoid fracture fixation through combined approaches. Evaluations were performed using the Mayo Elbow Performance Score (MEPS) and anteroposterior and lateral radiographs of the elbow.

Results

Twenty-two patients (15 males, seven females; mean ± SD age, 47.5 ± 11.4 years) were enrolled in this study. Fracture union and concentric reduction of both the ulnotrochlear and radiocapitellar articulations were achieved in all patients. The mean ± SD follow-up was 31.6 ± 11.9 months. The mean ± SD arc of flexion–extension was 110.3° ± 26.3° and arc of forearm rotation was 139.5° ± 17.1°. The mean ± SD MEPS was 88.1 ± 12.2 points, with results classified as excellent in eight elbows, good in ten, and fair in four. Six patients had radiographic signs of post-traumatic arthritis. Three patients required secondary surgeries.

Conclusion

Combined surgical approaches can be considered for the treatment of terrible triad injuries in association with anteromedial coronoid fractures.