Operative Treatment of Terrible Triad of the Elbow via Posterolateral and Anteromedial Approaches

Terrible Triad Injuries around the Elbow: It is Still a Puzzle? Prospective Study

Introduction

The "terrible triad" injury of the elbow, consisting of fractures of the coronoid process and radial head along with posterolateral elbow dislocation and refractory instability, has historically led to poor functional outcomes. Traditional treatment focused on bony injuries, but it is now recognized that soft-tissue injuries must also be addressed. Surgical management aims to restore bony and soft-tissue stabilizers, including fixation of the coronoid process and radial head, repair of ligament complexes, and reduction of elbow dislocation. Studies emphasize the importance of early reduction and tailored treatment. This study discusses means and methods of treating this complex injury, highlighting the significance of addressing both bony and soft-tissue injuries for better functional outcomes.

Materials and Method

This is a prospective study conducted at a single center and involved 27 consecutive patients diagnosed with terrible triad injuries around the elbow. The objective was to evaluate functional outcomes and complications associated with surgical treatment of terrible triad injuries around the elbow. From July 2017 to October 2018, 27 patients with terrible triad injuries around the elbow were operated on and evaluated for a minimum of 1 year in terms of functional results using the mean elbow performance score (MEPS) and VAS score. The surgical protocol included coronoid fixation or repair of the anterior capsule, radial head fixation or arthroplasty, and repair of the lateral collateral ligament (LCL) in a sequential manner. The medial collateral ligament was repaired if the elbow remained unstable.On follow-up, mean MEPS scores improved significantly. The final mean range of motion of the operated upper limb was as follows: 28.5° of extension deficit (standard deviation [SD] 9.07, range, 10°-40°), 117.5° of flexion (SD 13.18, range, 90°-130°), 70.9° of supination (SD 10.19, range, 40°-85°), and 65.5° of pronation (SD 9.54, range, 40°-80°) at the end of 1 year. A total of 12 patients had complications. Out of the 12 patients, three had elbow arthritis, two had heterotopic ossification, three had radial nerve neuropraxia, two patients had elbow stiffness, and two patients suffered from ulnar nerve neuropathy.

Conclusion

Surgical intervention in terrible triad injuries around the elbow in the form of coronoid fixation, radial head fixation, or arthroplasty and soft-tissue repair around the elbow gives satisfactory results at the end of 1 year. Addressing each and every component of fracture in a sequential and step-wise manner is associated with good functional outcomes at the end of 1 year.

Surgical treatment of terrible triad of the elbow: Retrospective continuous 50-patient series at 2 years' follow-up

INTRODUCTION

Terrible triad (TT) of the elbow is an association at high risk of instability. Treatment aims to restore joint stability. Lateral collateral ligament (LCL) repair is systematic, whereas medial collateral ligament (MCL) repair is only exceptionally necessary. The main aim of the present study was to assess clinical results in TT surgery. The secondary objective was to compare clinical progression with versus without MCL repair.

MATERIAL AND METHODS

A retrospective study included 50 TTs operated on via an isolated lateral or combined medial-lateral approach. Clinical assessment comprised MEPS, QuickDASH, VAS, flexion-extension and pronation-supination, and return to work and sport. Subgroup analysis was made according to associated MCL repair.

RESULTS

Fifty patients (19 female, 31 male) were operated on between January 2006 and January 2017. Mean follow-up was 24 months. At last follow-up, mean MEPS was 89.1, VAS 0.7, QuickDASH 16, flexion-extension 114°, and pronation-supination 137°. Only MEPS was significantly improved by MCL repair (p=0.02), with no significant difference in complications.

DISCUSSION

TT surgery with immediate mobilization gave good long-term functional results, not significantly improved by MCL repair. The lateral approach should be adopted in first line, with the medial approach in second line in case of persistent instability after lateral osteo-ligamentous repair.

LEVEL OF EVIDENCE

IV; retrospective study.

Comparing Options for Heterotopic Ossification Prophylaxis following Elbow Trauma: A Systematic Review and Meta-Analysis

Introduction  Heterotopic ossification (HO) can be a potentially serious and devastating complication following traumatic injury to the elbow. HO prophylaxis options include nonsteroidal anti-inflammatory drugs (NSAIDs) and radiation therapy (RT) but neither has been proven more effective. The purpose of this review is to compare effectiveness and outcomes between NSAID and RT prophylaxis for HO about the elbow following a traumatic injury. Materials and Methods  We performed a systematic review of PubMed and Cochrane Library for cases of HO prophylaxis following elbow trauma utilizing PRISMA guidelines to determine the most effective form of prophylaxis. Outcomes of interest included recurrence of HO, range of motion (ROM), and Mayo elbow performance index (MEPI). A total of 36 articles and 826 elbows of which 203 received RT and 623 received NSAID were identified and included in the final analysis. Results  Rates of HO formation or recurrence following elbow trauma were similar between radiation and NSAID prophylaxis (15.6% vs. 22.2%, respectively p = 0.457). ROM was similar in flexion and extension arc (109.0 degrees in radiation vs. 112.8 in NSAIDs, p = 0.459) and in pronation and supination arc (118.9 degrees radiation vs. 134.7 degrees NSAIDs, p = 0.322). MEPI scores were 79.19 in the radiation group and 88.82 in the NSAIDs group at the final follow-up. Conclusion  There is no statistical difference in HO development, recurrence, or final ROM between NSAIDs and RT prophylaxis following trauma to the elbow. We recommend the choice of modality based on patient characteristics, cost, and surgeon preference. Level of Evidence  Level III.

Analysis of twenty-five cases of terrible triad injury of the elbow surgically treated with a single lateral approach

BACKGROUND

The objective was to analyze the long-term clinical outcome of terrible triad injury of the elbow following surgical intervention with a single lateral approach.

METHOD

We treated twenty-five patients with terrible triad injury of the elbow from July 1, 2017, to June 30, 2020, and performed post hoc analysis. All patients underwent standardized surgery which entailed: plate fixation for the ulnar coronoid process, fixation or replacement of the radial head, and repair of the lateral ligament but not the medial collateral ligament.

RESULTS

We followed up each patient for an average of 22.9 months (range, 12 to 36 months) after surgery. Patients had an average angle scope of elbow flexion and extension that ranged from 8° to 120°. Average pronation of the elbow was 75° (range, 10°-85°), and average supination was 72° (range, 25°-80°). Patient-reported outcome measures were excellent: the DASH and Mayo elbow performance score (MEPS) were 96%. We were unable to follow-up one patient (4%). Among the remaining 24 patients, one patient (4%) presented with heterotopic ossification and stiffness following arthrolysis in the elbow one year after the initial surgery. We did not observe any joint dislocation, subluxation, or joint instability in the elbow after surgery.

DISCUSSION

The single lateral approach, a sequential surgery for terrible triad injury of the elbow, can improve initial stability of the elbow. Patients are able to perform rehabilitative exercises sooner in their recovery, which helps to reduce stiffness. Heterotopic ossification is also reduced.

Comparison of Surgical Techniques for Fixation of Terrible Triad Injuries of the Elbow: A Meta-Analysis

Treatment of the terrible triad injury of the elbow remains a difficult problem. There are several ways to treat the radial head and coronoid fractures; controversy still exists regarding the best way to treat each. The purpose of this meta-analysis was to compare the clinical outcomes of radial head and coronoid fractures treated using current protocols. No differences in functional outcomes were found between the different surgical techniques. There is no superior current protocol for treating these injuries. Surgical treatment should be dictated by fracture type and surgeon experience. [Orthopedics. 2020;43(6):328-332.].

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.

Outcomes following surgical management of complex terrible triad injuries of the elbow: a single surgeon case series

BACKGROUND

Terrible triad injuries of the elbow are complex injuries to treat and we report our outcomes following surgical management.

METHODS

Twenty-two consecutive patients who underwent fixation of terrible triad injuries between 2007 and 2012 were identified. Clinical outcomes were assessed by examination, visual analogue scores (VAS), Oxford Elbow Score (OES), Mayo Elbow Performance Index (MEPI) and QuickDash score (QD).

RESULTS

The mean age of patients was 47 years, with a mean follow-up of 32 months. All patients underwent lateral ligament repair, with additional medial ligament repair in four cases. Thirteen patients required repair of the coronoid and 18 patients required surgery to the radial head. The mean flexion-extension arc was 113°, with mean prono-supination of 136°. The functional elbow scores revealed good outcomes in the majority (mean OES of 37, MEPI of 79 and QD of 21). The overall complication rate was 41%. In total, 23% required reoperation, with one patient requiring fasciotomy for acute compartment syndrome and four requiring subsequent removal of metalwork as a result of stiffness.

CONCLUSIONS

Recognition of this complex injury pattern and appropriate restoration of the joint stability are the prerequisites. Systematic surgical approach is effective and can provide both stability and good function, in most cases.

Evaluation of effect and safety of arthroscopic surgery with three different operative approaches in patients with terrible triad of the elbow: A comparative study

BACKGROUND

The terrible triad of the elbow (TTE) is a difficult injury, and the usual TTE consists of posterior dislocation of the elbow, radial head fracture, and coronoid fracture. The target of this retrospective study is to explore the effect, postoperative complications, and prognostic factors in patients with TTE undergoing arthroscopic surgery with three different operative approaches.

METHODS

Patients with TTE underwent arthroscopic surgery were treated using lateral, anterior medial, or combined lateral and anterior medial approaches, respectively. In order to analyze the postoperative complications and the effect of arthroscopic surgery for patients with TTE, the function of elbow joint before and after the surgery was evaluated and the flexion-extension of elbow joint and rotation of elbow joint and forearm were measured.

RESULTS

The evaluation results obtained from patients underwent 3 different operative approaches revealed that after surgery, patients receiving arthroscopic surgery using combined lateral and anterior medial approach had superior flexion-extension of elbow joint, rotation of elbow joint and forearm, higher Mayo Elbow Performance Score (MEPS) and more cases of Broberg-Morrey grade 0, and lower complication rate, compared with those using lateral or anterior medial approach. A key finding in the study demonstrated that fracture type, operative approach, and postoperative complications were factors related with the effect of arthroscopic surgery for patients with TTE.

CONCLUSION

Collectively, the key findings obtained from the present study supported the notion that the effect of arthroscopic surgery in combined lateral and anterior medial approach is much better than in lateral approach or anterior medial approach, and is related with fracture type, operative approach, and postoperative complications.

Operative treatment of terrible triad of the elbow with a modified Pugh standard protocol: Retrospective analysis of a prospective cohort

The aim of the present study was to investigate the efficacy of the surgical treatment of terrible triad injuries of the elbow using a modified standard surgical approach, and treatment determined by the mode and mechanism of injury, and intraoperative findings.The study was a retrospective analysis of a prospective cohort of patients presenting with terrible triad injuries of the elbow, who underwent surgical treatment between July 2009 and January 2014. All patients were treated surgically according to a modified Pugh standard protocol. Elbow functional status and range of movements were evaluated at 3 months, 6 months, 1 year, and 2 years or more after surgery. Radiographic signs of post-traumatic arthritis were rated according to the Broberg and Morrey system.Our series included a final cohort of 29 males and 13 females with a mean age of 48.23 ± 10.95 years at the time of injury. The mean follow-up period was 30.47 ± 7.65 months. The mean flexion-extension arc was 107° ± 22°, and the average forearm rotation arc was 145° ± 14°. The mean Mayo Elbow Performance Score was 88 ± 10 points (range 55 to 100 points), with excellent results in 24 elbows, good results in 16, and poor results in 2. Functional results of the elbow improved significantly from 3 months postoperatively (P < .05), but tended to plateau from 1 year after surgery. Thirteen patients had radiographic signs of arthrosis (9 grade 1, 4 grade 2). Postoperative complications were local infection around the incision (n = 1), transient postoperative median nerve paralysis (n = 1), and postoperative posterior interosseous nerve paralysis (n = 1). Four patients required further surgery. Five patients had evidence of heterotopic ossification.Overall, we show that slight modifications to Pugh standard protocol for the surgical treatment of terrible triad injuries can lead to good to excellent results, although there were a good number of complications. The ideal surgical approach and treatment should be based on the mode and mechanism of injury, and intraoperative findings, and modifying the standard surgical treatment approach for terrible triad elbow injuries may be beneficial.

Elbow Posterolateral Dislocation Accompanying Flexor Group Origo Rupture without Fracture - A Case Report

INTRODUCTION

We wished to present a case that had elbow posterolateral dislocation accompanying complete medial collateral ligament rupture(MCLR) and complete flexor group origo rupture (FGOR) without fracture.

CASE REPORT

A30-year-old man came to emergency department after falling on the outstretched palm. After first physical examination and radiologic searches, elbow joint posterolateral dislocation was diagnosed. Together with sedoanalgesia, elbow dislocation was reduced, and instability evaluation by applying varus and valgus stress tests was performed. Positive valgus stress test and palpation sign which indicated soft tissue damage on the medial side of elbow were determined. Control roentgenograms showed no osseous pathology. By magnetic resonance imaging, elbow dislocation diagnosis accompanying MCLR and FGOR without fracture was confirmed. Using medial approach, ruptured MCL and elbow FGO repairing procedures were performed.

CONCLUSION

The complications of elbow dislocation without fracture, which is barely seen, should be treated through appropriate treatment strategies after meticulous physical examination and radiologic evaluation. Hence, possible sequelae could be prevented or satisfactory results could be obtained.

Evaluation of a combined posterior lateral and anteromedial approach in the treatment of terrible triad of the elbow: A retrospective study

BACKGROUND

This retrospective study aims to investigate the efficacy and safety of a combined posterior lateral and anteromedial approach in the treatment of terrible triad of the elbow (TTE).

METHODS

TTE patients who received a combination of posterior lateral and anteromedial approach or other conservative treatments were included in the present study. The postoperative functions of the elbow and the severity of traumatic arthritis were assessed using the Mayo Elbow Performance Score (MEPS) and visual analog scale (VAS). Extension-flexion of elbow joint and rotation of forearm were also measured.

RESULTS

A combined posterior lateral and anteromedial approach or other conservative treatments showed significant improvements in the activity of the elbow, MEPS, VAS, the excellent rate, and x-ray results. The postoperative healing time and complication rate of patients who received a combined posterior lateral and anteromedial approach significantly decreased compared to those who received other conservative treatments.

CONCLUSIONS

Patients with TTE who received a combined posterior lateral and anteromedial treatment had an increased fracture healing rate, showed improved recovery of elbow functions and had fewer complications.

Surgical Outcomes and Complications in Treatment of Terrible Triad of the Elbow: Comparisons of 3 Surgical Approaches

BACKGROUND This study compared the efficacy of combined lateral and medial approach, lateral approach, and anterior medial approach in treatment of terrible triad of the elbow (TTE). MATERIAL AND METHODS Thirty-eight TTE patients hospitalized in our center were retrospectively analyzed, among which 14 patients were arranged for combined lateral and medial approach, 12 for lateral approach, and 12 for anterior medial approach. All included patients underwent open reduction, collateral ligament repair, and postoperative function exercise. Follow-up was conducted for 13~22 months. The elbow motion, excellent and good rate, healing time, and complication rate were recorded and compared. RESULTS These 3 approaches significantly improved the postoperative elbow motion, MEPS, VAS, excellent and good rate, and open reduction (all P<0.05). The VAS score for lateral approach was evidently higher than that for combined lateral and medial approach (P<0.05). Combined lateral and medial approach and anterior medial approach had better performance on elbow motion, MEPS, and excellent and good rate than lateral approach (both P<0.05). Lateral approach and anterior medial approach had a significantly reduced healing time compared with combined lateral and medial approach (both P<0.05), while anterior medial approach had a higher complication rate compared with anterior medial approach and lateral approach (both P<0.05). CONCLUSIONS Lateral combined medial surgery approach contributes to wide surgical exposure, facture stability, and decreased complication rate, and thus has superior efficacy than the other 2 surgical approaches.